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
Precertification
Recertification
Urgent reason: Complete this form and fax it to 1-866-411-2573 for commercial contracts or send an e-fax or email to
[email protected]. For URMBT, fax form to 1-866-915-9811 or send an e-fax or e-mail to
[email protected]
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 guarantee a 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____. 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 When Completed
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Assessment type/coverage Facility type:
SNF
Acute Inpatient Rehabilitation Number of days requested:
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
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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 12173 APR 16 Page 2 of 2
Other
Home/number of steps at:
Entry: Bed/bath:
Discharge barriers:
3
