UM Guidelines

	Added:

Skilled Nursing Facility/Inpatient Rehabilitation Fax Form

FAX #: 423.535.3268, 1.888.423.9490     TELE. #: 1.800.228.2096

Exceptions may be required to comply with EPSDT & TennCare regulations.

Initial Request__________             Concurrent Review__________ Inpatient Rehabilitation [ ]              Skilled Nursing Facility [ ] Level I [ ]              Level II [ ]              Level III [ ] Commercial             BlueCare             TennCareSelect 423.535.______              423.535.7000

Member Information Member Name: ________________________ Date of Birth: ______________________ Member Identification Number: _____________ Reference Number:________________ Member Current Telephone Number: _______________________

Facility Information Date of Admission to Facility: ____________________________________ Facility Name:_________________________ Contact Name: _____________________ Address: ________________________________________________________________ Phone Number: _______________________ Fax Number: _______________________ Provider Number: __________________ Tax Identification Number:________________ Facility member is transferring from: ________________________________________

Admitting Provider Information Prescribing Provider's Name:____________________________________________________ Address: ____________________________________________________________________ Phone Number: ___________________________ Fax Number: _______________________ Provider Number _______________________ Tax Identification Number: ________________

Clinical Information Diagnosis: __________________________________________________________________ Height: __________ Weight: __________ Current Lab (e.g., hemoglobin & hematocrit, INR, PTT): ______________________________ Has a Doppler study of the lower extremities been performed? Yes [ ] No [ ] If yes, date of the last Doppler study (lower extremities)? _______________________ Patient Level of Orientation Rancho Level          [ ] Alert and Oriented     [ ] Willing and Able to Participate     [ ] Can Follow Commands Types of Discipline (Therapy):     [ ] Speech     [ ] Occupational      [ ] Physical Number of Therapy Hours per Day: _______________________________________________ Type of Surgery: ______________________________________________________________ Date of Surgery: ______________________________________________________________ Pain Control (by discharge): [ ] PO   [ ] IV   Please specify:___________________________ ____________________________________________________________________________ Comorbidity/Past Medical History:________________________________________________ Functional Status Prior to Admission: ____________________________________________ __________________________________________________________ Home Environment: Single or Multi Level: _____________  Number of steps to enter home: _____________ Number of steps within home: ______________  Availability of caregiver: _____________

Current Functional Status (DAY PRIOR TO DISCHARGE from Acute Care Facility): FIMS Score (1 - 7):    Minimum Moderate Maximum  CGA SBA Assistive Devices EATING             DRESSING             BATHING             BED/MOBILITY             SUPINE-SIT             SIT-STAND             TRANSFERS             AMBULATION **DISTANCE**

Wound Care description: (length, width, drainage), treatment, frequency: Progress toward goals/Changes in Plan of Care: Caregiver teaching/training: If Skilled Nursing Facility request, what are other skilled needs? (i.e., IV antibiotics, TPN, oxygen, CPM etc.) Please be specific regarding dosage amounts, frequencies and CPM settings: ____________________________________________________________________ ____________________________________________________________________ Requested length of stay and/or additional days requested:___________________

Behavioral Health Organization Issues (if applicable): Discharge Goals: Destination/Functional (Home with or without assist, Facility, etc.) __________________ _________________________________________________________________________ _________________________________________________________________________

 

Benefits are administered by Volunteer State Health Plan, Inc., a licensed HMO affiliate of BlueCross BlueShield of Tennessee, Inc.

BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association

® Registered marks of the BlueCross BlueShield Association, an Association of Independent BlueCross BlueShield Plans