LTACH Fax Assessment Form - bcbsm.com

Medicare Plus Blue PPOSM InterQualOR criteria MET InterQualOR criteria Not MET RE-SENDING FAX

LTACH Fax PRECERTIFICATION RECERTIFICATION

Assessment Form Complete this form and fax it to:
1-866-464-8223
A nonprofit corporation and independent licensee
of the Blue Cross and Blue Shield Association Or E-FAX/E-Mail to [email protected]

Include hospital admission H&P and PM&R consultation notes (as applicable)
LTAC weaning program. The precertification and recertification process is not a guarantee of payment.LTAC medical
. This fax form is completed by licensed clinical personnel.
. Facility and provider must participate with local BCBSM plan or member may incur sanctions.
. Please verify eligility and benefits prior to request.

Complete every field unless otherwise noted. Information must be legible. Enter N/A if not applicable.

INCOMPLETE SUBMISSIONS WILL BE RETURNED UNPROCESSED.

CONTACT INFORMATION

Contact name Title Signature

Date Contact phone number Fax number E-mail

Name PATIENT INFORMATION Policy number ZIP code
Address State
Age

City

Admission date (LTACH) Number of days requested ADMISSION DEMOGRAPHICS Estimated length of stay (# of days)
PRECERTIFICATION Facility phone number
Participates w/local MA PPO: Yes No
Facility address Facility name (LTACH) ZIP code
State ZIP code
Admitting physician (LTACH) name/address Facility NPI number State

City

City

Physician provider identification # Physician phone number Transfer from (facility name) Other: Home Dr’s office

Acute hospital admission date Admitting diagnosis with synopsis of acute hospital admission (include pertinent radiology results)

RECERTIFICATION
Number of days requested Current estimated length of stay Last covered date Total number of days previously approved

CURRENT CLINICAL INFORMATION

Height Weight BP HR Resp Rate Temp

Acute diagnosis (LTACH)

Treatments: Medical condition stabilized
Medical history: Yes No

Surgeries/Procedures Date
1) Date

2) VENT WEANING/RESPIRATORY COMPLEX
Oximetry
Vent rate Vent: Venti mask/Liters NC/Liters
Yes No

Setting PEEP FiO2

Tracheostomy: Yes No Date inserted Decanulation trial

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Clinical Status If no, provide reason:
No
CXR Stable/Improving Yes No
Yes No
Telemetry/Cardiac rhythm Yes No N/A
Yes No N/A
Neurologically stable last 24 hours Yes No N/A
Continuous sedation/Paralytic agent infusions Yes

NYHA Class < IV

Spontaneous breathing trial
Respiratory therapies

Chest physiotherapy Frequency: Nebulizer treatments Frequency:
Suctioning Frequency:
Oxygen adjustments Frequency: Blood products: Yes
(based on oximetry)

Hct Hgb Date Stable: Yes No No
Most current:

Other pertinent lab results

Invasive lines

IV medications Ending date

Ending date

Feeding tube: Yes No New to patient: Yes Amount of feeding Duration
No 1-3 hrs/day x5 days/week
Rehabilitation therapy: Yes No Modality:
PHYSICAL THERAPY

PT OT SLP Therapy tolerance:

Bed mobility: Total assist Max Min CGA SBA SUPV Ind
Transfers: Total assist Max Min CGA SBA SUPV Ind

Ambulation distance Ambulation device(s)

Ambulation assistance: Total assist Max Min CGA SBA SUPV Ind

Stairs: N/A #Stairs: Total Assist Max Min CGA SBA SUPV Ind Device:

Bathing: Upper body Total assist Max OCCUPATIONAL THERAPY Ind
Bathing: Lower body Total assist Max Ind
Dressing: Upper body Total assist Max Min CGA SBA SUPV Ind
Dressing: Lower body Total assist Max Min CGA SBA SUPV Ind
Toileting/Hygiene: Total assist Max Min CGA SBA SUPV Ind
ADL/Toileting transfers: Total assist Max Min CGA SBA SUPV Ind
Min CGA SBA SUPV
Min CGA SBA SUPV

None Dysphagia evaluation SPEECH THERAPY

Modified barium swallow results

Risk/Recommendations

*Overall focus goal of therapy(s)

SKIN STATUS

Intact Wound/Incision location #1 Stage: I II III IV Unstageable Size: L x W x D (cm)

Description

Treatment Frequency

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Intact Wound/Incision location #2 Stage: SKIN STATUS continued Size: L x W x D (cm)
Description
I II III IV Unstageable

Treatment Frequency

Comments ( use additional pages if necessary)

PAIN STATUS

Pain: Yes No Location Rating (out of 10)
Rating
Pain meds Effective: Yes No

DISCHARGE PLANS (needs to be initiated upon admission)

Discharge date (tentative/actual) Assistive devices

Resides: Alone w/Spouse w/Other Support: Spouse Children Family/Friend HHC Other

Home description (levels, bed/bath location, steps to enter, etc.)

Discharge to home : Yes No ALOC: Rehab SNF LTC Assisted living Other
Signature Title Date

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