Get MI BCBS Acute Inpatient Assessment Form 2013
RESET Acute Inpatient Fax Assessment Form R criteria MET InterQual O RE-SENDING FAX Recertification Complete this form and fax it to 1-866-411-2585 Or E-FAX/E-Mail to AcutePrecertification1 bcbsm.com Include hospital admission H P and PM R consultation notes as applicable A nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association Facility and provider must participate with local BCBS plan or claims may not pay. If facility/provider is not participating with member s contract network member sanction/fees may apply. Precertification does not guarantee payment. Please verify eligibility and benefits prior to request. Complete every field unless otherwise noted* Information must be legible. Place N/A if not applicable. Do not send a medical record review. Incomplete submissions will be returned unprocessed* HUMAN ORGAN TRANSPLANT Is there a potential of this member receiving a human organ transplant during this admission Yes No If Yes Has a prior authorization been completed with BCBSM s Human Organ Transplant Program HOTP If not please call the HOTP department at 1-800-242-3504. Title Contact name CONTACT INFORMATION Contact phone number Date Signature Fax number E-mail PATIENT INFORMATION Phone number Name City Address PRECERTIFICATION ER admit Direct admit Elective admit Observation Date of birth Policy number State ZIP code Estimated length of stay Admission date Facility name Facility NPI number Admitting physician Physician provider NPI number Facility phone number Physician phone number SURGICAL ADMISSIONS Surgical procedure and CPT codes Surgery date Number of days requested Current estimated length of stay Last covered date MEDICAL ADMISSIONS Admitting diagnosis and ICD9 codes Height ER/Admission assessment and treatment WF 12475 JAN 13 Page 1 of 2 BP HR Resp rate Temp Medical history/Co-morbidities/Family history Pertinent lab/Imaging/Other test results Admission orders/Current treatment plan Current medications/frequency SKIN STATUS Wound/Incision location 1 Intact Stage I II III IV Unstageable Size L x W x D cm Description Frequency Treatment Pain PAIN STATUS Rating out of 10 Location Pain meds/Frequency Effective Rating CASE MANAGEMENT BCBSM offers case management assistance for discharge planning. Would you like a referral made to our case management department Discharge plans needs to be initiated upon admission Discharge date tentative Resides Alone Assistive devices w/Spouse w/Other Support Family/friend Children HHC Home description levels bed/bath location steps to enter etc* Discharge to home Actual discharge date ALOC Rehab SNF LTC Assisted living. If facility/provider is not participating with member s contract network member sanction/fees may apply. Precertification does not guarantee payment. Please verify eligibility and benefits prior to request. Precertification does not guarantee payment. Please verify eligibility and benefits prior to request. Complete every field unless otherwise noted* Information must be legible. Place N/A if not applicable. .
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