Medicare Plus Blue PPO Skilled Nursing Facility, Acute

Title: Medicare Plus Blue PPO Skilled Nursing Facility, Acute Inpatiet Rehabilitation Facility Fax Assessment Form Subject: Medicare Plus Blue PPO Ski...

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Medicare Plus Blue SM PPO Skilled Nursing Facility, Acute Inpatient Rehabilitation Facility Fax Assessment Form

A nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association

Re-sending fax

Recertification

Precertification

Urgent reason: For Medicare Plus Blue SM PPO, call 1-866-464-8223 or send an e-fax or email to [email protected]. ATTN Michigan providers: for admission authorization of BCBSM members who reside in Michigan, please contact eviCore Healthcare at 1-877-917-BLUE or fax this form to eviCore at 844-407-5293

Facility and provider must participate with local Blue Cross Blue Shield plan or member may incur higher costs. Complete every field unless otherwise noted. Information must be legible. Place N/A if not applicable. Precertifications and Recertifications are not a guarantee of payment. Incomplete submissions will be returned unprocessed. Disclaimer Statements and Attestation • Please allow 24 hours for processing precertification and recertification requests. • Please verify eligibility and benefits prior to request. SNF/Rehab benefits Verified No Yes. Yes, number of days available____. Commercial Medicare exhaust: A copy of the Medicare Common Working File (HIQACRO screen) must be included with the precertification/recertification request. Yes No • All therapy notes are within 24 to 48 hours of admission date or last covered date (only choose one answer) • SNF member is receiving at least 1 hour of therapy 5 days a week (only choose one answer) Yes No • Acute rehab member is receiving OT or PT at least 3 hours per day, 5 days per week and able to sit for 1 hour a day (only choose one answer) Yes No

6LJQDQGGDWHKHUH Facility type:

When Completed

Assessment type/coverage Acute Inpatient Rehabilitation Number of days requested:

SNF

7 days

10 days

ELOS (# of days)

Member/facility information

Member name

Address

Date of birth

Policy number

Hospital

Member phone number Facility PIN number

Admitting facility and NPI number Fax number

Phone number

Admission date Facility reviewer name

Address

Admission Information Admission date to SNF/IPR

Clinical information/basics

Admitting doctor (first/last name and NPI#)

Vital signs: T

Physician address/phone number Hospital admitting diagnosis and ICD-10 CM code

Continent

BP Incontinent

Bladder:

Continent

Incontinent

NPO Yes

Type: No

Cath/Type:

Complications Surgical procedure

Date

Yes

No

O2 delivery:

None or

Type:

Vent:

Prior level of function (home)

Respiratory tx:

Yes

Sat:

Freq: No

None or

Freq: Type:

Pain location: Pain medication: Mod

Min

Bed mobility:

Total assist

Max assist

CGA

SBA

Mod Ind

Ind

Transfers:

Total assist

Max assist

Mod

Min

CGA

SBA

Mod Ind

Ind

WF 15674 APR 16 Page 1 of 2

No

None or

Trach:

Focus goal of physical therapy

Gait/distance

Yes

Vent Settings: Suction frequency/24H:

Mobility current functioning Date of PT/OT notes:

or

IV/PICC line:

Medical history

Weight

P

R Bowel:

Diet: Tube feeding:

Height

14 days

Route

Frequency

Dose

Pain scale:

Before management

After management

Clinical information/cognition Alert and oriented X

Other:

Mobility current functioning (continued) Gait/assist needed:

Total assist CGA

SBA

Gait/assistive device:

None or

Type:

Stairs:

Max assist

Mod Mod Ind

Clinical information/medications Min Ind

List significant medication changes at reassessment that affect functioning:

List IV medications (medication name, dose, frequency, start date, end date):

1.) Current number of stairs can climb: 2.) Number of stairs in home:

Stairs/assist needed:

Total assist

Max assist

Mod

Min

CGA

SBA

Mod Ind

Ind

Medication name

Comments:

Dose

Frequency

Start date

End date

Ending date

Clinical information/skin status

Self-care current functioning Focus occupational therapy goals:

Skin status:

Intact

If not intact, complete fields below and add pages as needed.

Wound or incision/Location and stage:

Bathing/UE: Bathing/LE: Dressing/UE: Dressing/LE: Toileting/ Hygiene mgt: ADL transfers:

Total assist

Max assist

Mod

Min

CGA

SBA

Mod Ind

Ind

Total assist

Max assist

Mod

Size L x W x D (CM):

CGA

SBA

Mod Ind

Min Ind

Total assist

Mod Ind

Min Ind

Treatment

CGA

Max assist SBA

Total assist

Max assist

CGA

SBA

Mod Mod Ind

Min Ind

Total assist

Max assist

Mod

Min

Mod

CGA

SBA

Mod Ind

Ind

Total assist

Max assist

CGA

SBA

Mod Mod Ind

Ind

Wound or incision/Location and stage:

Min Size L x W x D (CM):

Speech therapy current status None

Dysphagia evaluation/Modified barium swallow Treatment type and frequency

Result/Aspiration risk/Recommendations:

Comment:

Discharge plans (must be initiated upon admission) Home evaluation date

Discharge date (tentative)

Home/number of levels:

1

2

Other: Discharge location

Home alone

HHC/company

Family/support

Assisted living

Long-term care

Adult foster care

Equipment: Supervision needs:

WF 15674 APR 16 Page 2 of 2

Other

Home/number of steps at:

Entry: Bed/bath:

Discharge barriers:

3