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  • Mi Wf 15674 2016

Get Mi Wf 15674 2016-2026

Fax it to: 1-866-464-8223 2U H ID HPDLO WR 0HGLFDUH3OXV%OXH)DFLOLW )D #EFEVP FRP ATTN Michigan providers: for admission authorization of Medicare Plus Blue PPO members who reside in Michigan, please contact eviCore Healthcare at 1-877-917-BLUE or visit eviCore's website at www.carecorenational.com/page/bcbsm-implementation.aspx and download the applicable assessment form. Facility and provider must participate with local Blue Cross Blue Shield plan or member may incur higher costs. Complete ev.

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  2. Carefully review each section of the form, ensuring you provide accurate and legible information. Fill in every required field, marking 'N/A' in spaces that are not applicable to your submission.
  3. Provide admission information such as the admission date to the skilled nursing facility or inpatient rehabilitation, including clinical details such as the admitting doctor's name, vital signs, and the hospital admitting diagnosis with the corresponding ICD-10 CM code.
  4. List any significant medication changes, IV medications, and declare the clinical information related to self-care and discharge plans. Make sure to fully describe any needs or barriers to discharge.

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