Get Tufts Health Plan Inpatient Notification Form 2022-2025

Filling out the TUFTS Health Plan Inpatient Notification Form is essential for notifying the health plan about inpatient admissions. This guide provides clear instructions to help you complete the form accurately and efficiently online.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to access the notification form online and open it for editing.
2. Fill in the requestor's details, including the requestor’s name, phone number, extension, and fax number. Ensure that these fields are accurate to facilitate communication.
3. Provide the member's information by entering their name, member ID number, and date of birth. This information verifies the individual's enrollment in the plan.
4. Enter the admitting physician's details, including their name, phone number, and National Provider Identifier (NPI) number. This ensures the correct physician is identified in the notification.
5. Complete the admitting facility information, including the facility's name, phone number, and NPI number. This helps designate where the admission will take place.
6. Specify the date of the inpatient admission and any prior observation date if applicable. Accurate dates are essential for record-keeping.
7. Fill in the ICD-10 diagnosis codes relevant to the admission. These codes are crucial for billing and insurance purposes.
8. Provide any applicable ICD-10 or CPT procedure codes that relate to the admission. This information helps clarify the medical necessity of the admission.
9. Enter the primary care provider's (PCP) name and indicate whether there is a PCP referral for this admission. Include the referral number if available.
10. Indicate if a prior authorization number exists and whether the procedure is elective. Mark 'Yes' or 'No' where required for clarity.
11. Detail the type of requesting status, including options like inpatient, observation, or scheduled surgical procedures. Select the correct status for the admission.
12. Include additional information about the level of care needed, such as SNF, rehab, or custodial levels. Fill these out based on the patient's requirements.
13. Finally, after reviewing all the entered information for accuracy, save changes and proceed to download, print, or share the completed form as needed.

Complete the TUFTS Health Plan Inpatient Notification Form online to ensure timely submissions.