home care authorization form
TRANSCRIPT
Home Care Authorization FormCUT6137-1E (6/18)
IMPORTANT 1. Claims submitted for these benefits are subject to lifetime maximums and any applicable deductions, coinsurances or
provisions, as specified in the member’s contract. Benefits issued for requested services will be subtracted from the member’s lifetime benefit maximum. Benefit approval is subject to the following conditions: a) member identification number is effective at the time services are rendered, b) requested benefits are available under the member’s contract, c) lifetime benefits not exhausted.
2. When submitting claims for habilitative services, the modifier 96 must be included. When submitting claims for rehabilitative services, the modifier 97 must be included.
3. Please contact the appropriate provider service area to verify member’s eligibility and benefits for requested services.
4. Claim payment for approved services does not indicate payment for future services. All future claims will be evaluated in accordance with the aforementioned benefit approval conditions and the CareFirst and/or CareFirst BlueChoice utilization management review process.
5. If you have any questions regarding the extent of this authorization, please call 800-334-3427 ext 4402. Calls will be returned within one business day.
Participating Providers: to initiate a request and to check the status of your request, visit CareFirst Direct at carefirst.com. Fax completed form to 410-720-5630 or 410-720-5641.
HOME CARE PROVIDER INFORMATION Home Care Provider Provider Phone # Agency Contact Name
Home Care Provider Address Provider Fax # Start of Care (SOC) Date
Provider ID # Date of Request
Email Address
MEMBER/PATIENT INFORMATION Last Name First Name M.I. Gender Date of Birth
Address (Street, Apt. or Box #), City State Zip Code
Member Group # Member ID # w/Prefix
Place of Hospitalization Hospital Admission Date Hospital Discharge Date
Physician’s Name and Complete Address
Diagnosis & Code(s) (ICD-10) Homebound
Skilled Nursing (SN) Medical Social Worker (MSW)
Physical Therapy (PT) Home Health Aide (HHA)
Nutritionist Occupational Therapy (OT)
Speech Therapy Private Duty Nursing (PDN) Hours per day______________
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst MedPlus is the business name of First Care, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc. and First Care, Inc., are independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
Location ________________________________________________ *If yes; must complete
1. Measurements: ________ Length _________ Width _________ Depth
2. Measurements: ________ Length _________ Width _________ Depth
Presence of Tunneling Yes No
Drainage _________ Color _________ Odor _________ Amount
Wound Vac? Yes No
SN __________ PT __________ OT __________ MSW __________ HHA __________
SLP __________ Other __________
Notice of Nondiscrimination and Availability of Language Assistance Services
CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.
CareFirst:
Provides free aid and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages
If you need these services, please call 855-258-6518.
If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you.
To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator as indicated below. Please do not send payments, claims issues, or other documentation to this office.
Civil Rights Coordinator, Corporate Office of Civil Rights Mailing Address P.O. Box 8894 Baltimore, Maryland 21224
Email Address [email protected]
Telephone Number 410-528-7820 Fax Number 410-505-2011
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:
U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
REV. (12/17)
Foreign Language Assistance Attention (English): This notice contains information about your insurance coverage. It may contain key dates
and you may need to take action by certain deadlines. You have the right to get this information and assistance in
your language at no cost. Members should call the phone number on the back of their member identification card.
All others may call 855-258-6518 and wait through the dialogue until prompted to push 0. When an agent
answers, state the language you need and you will be connected to an interpreter.
(Amharic) -
855-258-6518 0
Èdè Yorùbá (Yoruba) Ìttíléko: Àkíyèsí yìí ní ìwífún nípa i adójútòfò r. Ó le ní àwn déètì pàtó o sì le ní láti
gbé ìgbés ní àwn j gbèdéke kan. O ni t láti gba ìwífún yìí àti ìrànlw ní èdè r lf. Àwn m-gb
gbd pe nmbà fóònù tó wà lyìn káàdì ìdánim wn. Àwn míràn le pe 855-258-6518 kí o sì dúró nípas ìjíròrò
títí a ó fi s fún láti t 0. Nígbàtí aojú kan bá dáhùn, s èdè tí o f a ó sì so p m ògbuf kan.
Ting Vit (Vietnamese) Chú ý: Thông báo này cha thông tin v phm vi bo him ca quý v. Thông báo có th
cha nhng ngày quan trng và quý v cn hành ng trc mt s thi hn nht nh. Quý v có quyn nhn
c thông tin này và h tr bng ngôn ng ca quý v hoàn toàn min phí. Các thành viên nên gi s in thoi
mt sau ca th nhn dng. Tt c nhng ngi khác có th gi s 855-258-6518 và ch ht cuc i thoi cho
n khi c nhc nhn phím 0. Khi mt tng ài viên tr li, hãy nêu rõ ngôn ng quý v cn và quý v s c
kt ni vi mt thông dch viên.
Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ng impormasyon tungkol sa nasasaklawan ng iyong
insurance. Maaari itong maglaman ng mga pinakamahalagang petsa at maaaring kailangan mong gumawa ng
aksyon ayon sa ilang deadline. May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling
wika nang walang gastos. Dapat tawagan ng mga Miyembro ang numero ng telepono na nasa likuran ng kanilang
identification card. Ang lahat ng iba ay maaaring tumawag sa 855-258-6518 at maghintay hanggang sa dulo ng
diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot ang ahente, sabihin ang wika na kailangan mo
at ikokonekta ka sa isang interpreter.
Español (Spanish) Atención: Este aviso contiene información sobre su cobertura de seguro. Es posible que
incluya fechas clave y que usted tenga que realizar alguna acción antes de ciertas fechas límite. Usted tiene
derecho a obtener esta información y asistencia en su idioma sin ningún costo. Los asegurados deben llamar al
número de teléfono que se encuentra al reverso de su tarjeta de identificación. Todos los demás pueden llamar al
855-258-6518 y esperar la grabación hasta que se les indique que deben presionar 0. Cuando un agente de seguros
responda, indique el idioma que necesita y se le comunicará con un intérprete.
(Russian) !
. ,
.
. ,
.
855-258-6518 , «0».
, .
(Hindi) :
-
855-258-6518 0 ,
s-wùù (Bassa) To uu Cao! B nia k a ny e ke m gbo kpa o ni fu a-fa-tiin ny je dyi. B nia k
ee we j e m ke wa m m ke nyu nyu hw we ea ke zi. m ni kpe m ke b nia k ke gbo-
kpa-kpa m m dye e ni ii-wuu mu m ke se wii o p. Kpoo ny e m a fùn-na nia e waa
I.D. kaa ein ny. Ny t sein m a na nia k: 855-258-6518, ke m m fo tee wa ke m gbo c m ke
na ma 0 k dyi paain hw. ju ke ny o dyi m g juin, po wuu m m po dyi, ke ny o mu o niin
ke ni wuu mu za.
(Bengali) :
855-258-6518
0
: (Urdu )
0 6518-258-855
: . (Farsi )
. .
.
. 0 855-258-6518
.
: (Arabic)
. .
.
.0 855-258-6518
.
(Traditional Chinese)
855-258-6518
0
Igbo (Igbo) Nrbama: kwa a nwere ozi gbasara mkpuchi nchekwa onwe g. nwere ike nwe bch nd d
mkpa, nwere ike me ihe tupu fd bch njedebe. nwere ikike nweta ozi na enyemaka a n’ass g na
akwgh gw bla. Nd otu kwesr kp akara ekwent d n’az nke kaad njirimara ha. Nd z niile nwere
ike kp 855-258-6518 wee chere bb ah ruo mgbe amanyere p 0. Mgbe onye nnchite anya zara, kwuo
ass chr, a ga-ejik g na onye kwa okwu.
Deutsch (German) Achtung: Diese Mitteilung enthält Informationen über Ihren Versicherungsschutz. Sie kann
wichtige Termine beinhalten, und Sie müssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben
das Recht, diese Informationen und weitere Unterstützung kostenlos in Ihrer Sprache zu erhalten. Als Mitglied
verwenden Sie bitte die auf der Rückseite Ihrer Karte angegebene Telefonnummer. Alle anderen Personen rufen
bitte die Nummer 855-258-6518 an und warten auf die Aufforderung, die Taste 0 zu drücken. Geben Sie dem
Mitarbeiter die gewünschte Sprache an, damit er Sie mit einem Dolmetscher verbinden kann.
Français (French) Attention: cet avis contient des informations sur votre couverture d'assurance. Des dates
importantes peuvent y figurer et il se peut que vous deviez entreprendre des démarches avant certaines échéances.
Vous avez le droit d'obtenir gratuitement ces informations et de l'aide dans votre langue. Les membres doivent
appeler le numéro de téléphone figurant à l'arrière de leur carte d'identification. Tous les autres peuvent appeler le
855-258-6518 et, après avoir écouté le message, appuyer sur le 0 lorsqu'ils seront invités à le faire. Lorsqu'un(e)
employé(e) répondra, indiquez la langue que vous souhaitez et vous serez mis(e) en relation avec un interprète.
(Korean) : .
.
. ID .
855-258-6518 0 .
.
(Navajo)
855-258-6518
Physical Therapy 2: Off
Nutritionist 2: Off
Provider Name 4:
Provider Phone 4:
Agency Contact 4:
Provider Address 4:
Provider Fax 4:
SOC Date 2:
Provider ID 4:
Qualified sign language interpreters:
Written information in other formats large print audio accessible electronic formats other formats:
Qualified interpreters:
IMPORTANT 1. Claims submitted for these benefits are subject to lifetime maximums and any applicable deductions, coinsurances or
provisions, as specified in the member’s contract. Benefits issued for requested services will be subtracted from the member’s lifetime benefit maximum. Benefit approval is subject to the following conditions: a) member identification number is effective at the time services are rendered, b) requested benefits are available under the member’s contract, c) lifetime benefits not exhausted.
2. When submitting claims for habilitative services, the modifier 96 must be included. When submitting claims for rehabilitative services, the modifier 97 must be included.
3. Please contact the appropriate provider service area to verify member’s eligibility and benefits for requested services.
4. Claim payment for approved services does not indicate payment for future services. All future claims will be evaluated in accordance with the aforementioned benefit approval conditions and the CareFirst and/or CareFirst BlueChoice utilization management review process.
5. If you have any questions regarding the extent of this authorization, please call 800-334-3427 ext 4402. Calls will be returned within one business day.
Participating Providers: to initiate a request and to check the status of your request, visit CareFirst Direct at carefirst.com. Fax completed form to 410-720-5630 or 410-720-5641.
HOME CARE PROVIDER INFORMATION Home Care Provider Provider Phone # Agency Contact Name
Home Care Provider Address Provider Fax # Start of Care (SOC) Date
Provider ID # Date of Request
Email Address
MEMBER/PATIENT INFORMATION Last Name First Name M.I. Gender Date of Birth
Address (Street, Apt. or Box #), City State Zip Code
Member Group # Member ID # w/Prefix
Place of Hospitalization Hospital Admission Date Hospital Discharge Date
Physician’s Name and Complete Address
Diagnosis & Code(s) (ICD-10) Homebound
Skilled Nursing (SN) Medical Social Worker (MSW)
Physical Therapy (PT) Home Health Aide (HHA)
Nutritionist Occupational Therapy (OT)
Speech Therapy Private Duty Nursing (PDN) Hours per day______________
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst MedPlus is the business name of First Care, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc. and First Care, Inc., are independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
Location ________________________________________________ *If yes; must complete
1. Measurements: ________ Length _________ Width _________ Depth
2. Measurements: ________ Length _________ Width _________ Depth
Presence of Tunneling Yes No
Drainage _________ Color _________ Odor _________ Amount
Wound Vac? Yes No
SN __________ PT __________ OT __________ MSW __________ HHA __________
SLP __________ Other __________
Notice of Nondiscrimination and Availability of Language Assistance Services
CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.
CareFirst:
Provides free aid and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages
If you need these services, please call 855-258-6518.
If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you.
To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator as indicated below. Please do not send payments, claims issues, or other documentation to this office.
Civil Rights Coordinator, Corporate Office of Civil Rights Mailing Address P.O. Box 8894 Baltimore, Maryland 21224
Email Address [email protected]
Telephone Number 410-528-7820 Fax Number 410-505-2011
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:
U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
REV. (12/17)
Foreign Language Assistance Attention (English): This notice contains information about your insurance coverage. It may contain key dates
and you may need to take action by certain deadlines. You have the right to get this information and assistance in
your language at no cost. Members should call the phone number on the back of their member identification card.
All others may call 855-258-6518 and wait through the dialogue until prompted to push 0. When an agent
answers, state the language you need and you will be connected to an interpreter.
(Amharic) -
855-258-6518 0
Èdè Yorùbá (Yoruba) Ìttíléko: Àkíyèsí yìí ní ìwífún nípa i adójútòfò r. Ó le ní àwn déètì pàtó o sì le ní láti
gbé ìgbés ní àwn j gbèdéke kan. O ni t láti gba ìwífún yìí àti ìrànlw ní èdè r lf. Àwn m-gb
gbd pe nmbà fóònù tó wà lyìn káàdì ìdánim wn. Àwn míràn le pe 855-258-6518 kí o sì dúró nípas ìjíròrò
títí a ó fi s fún láti t 0. Nígbàtí aojú kan bá dáhùn, s èdè tí o f a ó sì so p m ògbuf kan.
Ting Vit (Vietnamese) Chú ý: Thông báo này cha thông tin v phm vi bo him ca quý v. Thông báo có th
cha nhng ngày quan trng và quý v cn hành ng trc mt s thi hn nht nh. Quý v có quyn nhn
c thông tin này và h tr bng ngôn ng ca quý v hoàn toàn min phí. Các thành viên nên gi s in thoi
mt sau ca th nhn dng. Tt c nhng ngi khác có th gi s 855-258-6518 và ch ht cuc i thoi cho
n khi c nhc nhn phím 0. Khi mt tng ài viên tr li, hãy nêu rõ ngôn ng quý v cn và quý v s c
kt ni vi mt thông dch viên.
Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ng impormasyon tungkol sa nasasaklawan ng iyong
insurance. Maaari itong maglaman ng mga pinakamahalagang petsa at maaaring kailangan mong gumawa ng
aksyon ayon sa ilang deadline. May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling
wika nang walang gastos. Dapat tawagan ng mga Miyembro ang numero ng telepono na nasa likuran ng kanilang
identification card. Ang lahat ng iba ay maaaring tumawag sa 855-258-6518 at maghintay hanggang sa dulo ng
diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot ang ahente, sabihin ang wika na kailangan mo
at ikokonekta ka sa isang interpreter.
Español (Spanish) Atención: Este aviso contiene información sobre su cobertura de seguro. Es posible que
incluya fechas clave y que usted tenga que realizar alguna acción antes de ciertas fechas límite. Usted tiene
derecho a obtener esta información y asistencia en su idioma sin ningún costo. Los asegurados deben llamar al
número de teléfono que se encuentra al reverso de su tarjeta de identificación. Todos los demás pueden llamar al
855-258-6518 y esperar la grabación hasta que se les indique que deben presionar 0. Cuando un agente de seguros
responda, indique el idioma que necesita y se le comunicará con un intérprete.
(Russian) !
. ,
.
. ,
.
855-258-6518 , «0».
, .
(Hindi) :
-
855-258-6518 0 ,
s-wùù (Bassa) To uu Cao! B nia k a ny e ke m gbo kpa o ni fu a-fa-tiin ny je dyi. B nia k
ee we j e m ke wa m m ke nyu nyu hw we ea ke zi. m ni kpe m ke b nia k ke gbo-
kpa-kpa m m dye e ni ii-wuu mu m ke se wii o p. Kpoo ny e m a fùn-na nia e waa
I.D. kaa ein ny. Ny t sein m a na nia k: 855-258-6518, ke m m fo tee wa ke m gbo c m ke
na ma 0 k dyi paain hw. ju ke ny o dyi m g juin, po wuu m m po dyi, ke ny o mu o niin
ke ni wuu mu za.
(Bengali) :
855-258-6518
0
: (Urdu )
0 6518-258-855
: . (Farsi )
. .
.
. 0 855-258-6518
.
: (Arabic)
. .
.
.0 855-258-6518
.
(Traditional Chinese)
855-258-6518
0
Igbo (Igbo) Nrbama: kwa a nwere ozi gbasara mkpuchi nchekwa onwe g. nwere ike nwe bch nd d
mkpa, nwere ike me ihe tupu fd bch njedebe. nwere ikike nweta ozi na enyemaka a n’ass g na
akwgh gw bla. Nd otu kwesr kp akara ekwent d n’az nke kaad njirimara ha. Nd z niile nwere
ike kp 855-258-6518 wee chere bb ah ruo mgbe amanyere p 0. Mgbe onye nnchite anya zara, kwuo
ass chr, a ga-ejik g na onye kwa okwu.
Deutsch (German) Achtung: Diese Mitteilung enthält Informationen über Ihren Versicherungsschutz. Sie kann
wichtige Termine beinhalten, und Sie müssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben
das Recht, diese Informationen und weitere Unterstützung kostenlos in Ihrer Sprache zu erhalten. Als Mitglied
verwenden Sie bitte die auf der Rückseite Ihrer Karte angegebene Telefonnummer. Alle anderen Personen rufen
bitte die Nummer 855-258-6518 an und warten auf die Aufforderung, die Taste 0 zu drücken. Geben Sie dem
Mitarbeiter die gewünschte Sprache an, damit er Sie mit einem Dolmetscher verbinden kann.
Français (French) Attention: cet avis contient des informations sur votre couverture d'assurance. Des dates
importantes peuvent y figurer et il se peut que vous deviez entreprendre des démarches avant certaines échéances.
Vous avez le droit d'obtenir gratuitement ces informations et de l'aide dans votre langue. Les membres doivent
appeler le numéro de téléphone figurant à l'arrière de leur carte d'identification. Tous les autres peuvent appeler le
855-258-6518 et, après avoir écouté le message, appuyer sur le 0 lorsqu'ils seront invités à le faire. Lorsqu'un(e)
employé(e) répondra, indiquez la langue que vous souhaitez et vous serez mis(e) en relation avec un interprète.
(Korean) : .
.
. ID .
855-258-6518 0 .
.
(Navajo)
855-258-6518
Physical Therapy 2: Off
Nutritionist 2: Off
Provider Name 4:
Provider Phone 4:
Agency Contact 4:
Provider Address 4:
Provider Fax 4:
SOC Date 2:
Provider ID 4:
Qualified sign language interpreters:
Written information in other formats large print audio accessible electronic formats other formats:
Qualified interpreters: