Form 15ped3339 - Skilled Nursing Facility/inpatient Rehabilitation Authorization Request
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2Skilled Nursing Facility/Inpatient Rehabilitation Authorization Request
1 Cameron Hill Circle
Commercial/FEP:
Fax: 1-866-230-3424
Chattanooga, TN 37402
BlueCare Tennessee:
Fax: (423) 535-7790/Phone: 1-888-423-0131
BlueAdvantage and BlueChoice
Fax: 1-888-535-5243/Phone: 1-800-924-7141
CoverKids
Fax: 1-800-851-2491/Phone: 1-800-924-7141
- Confidential
Initial Request: _________________________________ Concurrent Review: ______________________________
Inpatient Rehabilitation
Skilled Nursing Facility Level I Level II
Level III
Member Information
Member Name: _________________________________ Date of Birth: ___________________________________
Member Identification Number: _____________________ Reference Number: ______________________________
Member Current Telephone Number: ________________________________________________________________
SNF / Inpatient Rehabilitation Facility Information
Expected Date of Admission to Facility: ________________
Facility Name: __________________________________ Contact Name: _________________________________
Is the SNF/Inpatient Rehabilitation Facility "in network" with BlueCross BlueShield of Tennessee? Yes No
Address: ____________________________________________________________________________________
Phone Number: _________________________________ Fax Number: ___________________________________
Provider Number: ________________________________ NPI Number: ___________________________________
Facility member is transferring from: ________________________________________________________________
Ordering Physician Information
Prescribing Physician Name: ______________________________________________________________________
Is the Ordering Physician "in network" with BlueCross BlueShield of Tennessee? Yes No
Address: ____________________________________________________________________________________
Phone Number: _________________________________ Fax Number:____________________________________
Provider Number: ________________________________ NPI Number: ___________________________________
Admitting Physician Information
Facility Physician Name: _________________________________________________________________________
Is the Facility Physician "in network" with BlueCross BlueShield of Tennessee? Yes No
Address: ____________________________________________________________________________________
Phone Number: _________________________________ Fax Number:____________________________________
Provider Number: ________________________________ NPI Number: ___________________________________
Providers should obtain the above information for the online authorization process.
Clinical Information
Diagnosis: ___________________________________________________________________________________
Co Morbidity / Past Medical History: ________________________________________________________________
Height: __________ Weight: __________
Type of Surgery: ______________________________________________________________________________
Date of Surgery: ______________________________________________________________________________
Pain Control (at discharge): PO (by mouth) IV: Please specify: _________________________________________
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Parent category: Business