Get MI BCBS Acute Inpatient Assessment Form 2018-2021
Acute Inpatient Fax Assessment Form Re-sending fax Precertification A nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association Complete this form and fax it to 1-866-411-2585 For URMBT fax form to 1-866-915-9811 Include hospital admission H P and PM R consultation notes as applicable Please allow 24-48 hours for processing precertification and recertification requests. Precertification isn t a guarantee of payment. Facilities and other health care providers must verify patient eligibility and benefits prior to making precertification requests. If the facility or the provider isn t participating with the local plan claims may not pay. If the facility or provider isn t participating with a member s contract network a member may incur higher costs. This approval is based on an acute hospital stay only this is not an approval for long-term acute care facilities. All Commercial LTAC requests must be submitted on LTAC form* Incomplete submissions will be returned unprocessed* Human organ transplant If this admission is for an organ transplant and authorization has not been obtained please call the Human Organ Transplant Program department at 1-800-242-3504. Patient information Date of birth Name Policy number City Address Phone number ER admit Direct admit Elective admit ZIP code State Observation Estimated length of stay Admission date Facility phone number Facility name Facility NPI number Admitting physician Physician provider NPI number Physician phone number Number of days requested 3 days 5 days 7 days Current estimated length of stay Last covered date Facility contact information Signature Title Contact name Contact phone number Date Surgical procedure and ICD-10 CM PCS codes Fax number E-mail Surgical admissions Surgery date Medical admissions Admitting diagnosis and ICD-10 CM codes Height ER/admission assessment and treatment WF 12265 JUN 18 Page 1 of 2 BP HR Resp rate Temp Pulse Ox 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 Unstageable IV III Size L x W x D cm Description Frequency Treatment Pain status Pain Yes No Location Rating out of 10 Pain medications Dose effective Route Case management BCBSM offers case management assistance for discharge planning. Would you like a referral made to our case management department Discharge date tentative/actual Resides Alone w/Spouse Discharge plans needs to be initiated upon admission Assistive devices w/Other Support Children Family/friend Home health care Home description levels bed/bath location steps to enter etc* Discharge to home Alternative level of care Rehab Adult foster home Assisted living Skilled nursing facility Long term center. Precertification isn t a guarantee of payment. Facilities and other health care providers must verify patient eligibility and benefits prior to making precertification requests. If the facility or the provider isn t participating with the local plan claims may not pay. If the facility or provider isn t participating with a member s contract network a member may incur higher costs. .
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