Home Care Authorization Form - CareFirst

1 1 Home Care Authorization FormCUT6137-1E (6/18)IMPORTANT1. 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 When submitting claims for habilitative services, the modifier 96 must be included.

2 When submitting claims for rehabilitative services, the modifier 97 must be Please contact the appropriate provider service area to verify member s eligibility and benefits for requested 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 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 Providers: to initiate a request and to check the status of your request, visit CareFirst Direct at Fax completed form to 410-720-5630 or 410-720-5641.

3 HOME CARE PROVIDER INFORMATIONHome Care ProviderProvider Phone #Agency Contact NameHome Care Provider AddressProvider Fax #Start of Care (SOC) DateProvider ID #Date of RequestEmail AddressMEMBER/PATIENT INFORMATIONLast NameFirst of BirthAddress (Street, Apt. or Box #), CityStateZip CodeMember Group #Member ID # w/PrefixPlace of HospitalizationHospital Admission DateHospital Discharge DatePhysician s Name and Complete AddressDiagnosis & Code(s) (ICD-10)HomeboundServices requested (include number of visits per day/week/month) Skilled Nursing (SN) medical Social Worker (MSW) Physical Therapy (PT) Home Health Aide (HHA) Nutritionist Occupational Therapy (OT) Speech Therapy Private Duty Nursing (PDN)

4 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 , INFORMATIONW ound Present Yes No Location _____ *If yes; must complete1. Measurements: _____ Length _____ Width _____ Depth 2.

5 Measurements: _____ Length _____ Width _____ Depth Presence of Tunneling Yes No Drainage _____ Color _____ Odor _____ Amount Caregiver or Member instructed in wound care Yes NoWound Vac? Yes NoINTERNAL OFFICE USE ONLYA uthorization # and DateSN _____ PT _____ OT _____ MSW _____ HHA _____SLP _____ Other _____Notice of Nondiscrimination and Availability of Language Assistance ServicesCareFirst 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.

6 CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or : Provides free aid and services to people with disabilities to communicate effectively with us, such as:Qualified sign language interpretersWritten 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 interpretersInformation written in other languagesIf you need these services, please call 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.

7 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 Rights Coordinator, Corporate Office of Civil RightsMailing Address Box 8894 Baltimore, maryland 21224 Email Address Number 410-528-7820 Fax Number 410-505-2011 You can also file a civil rights complaint with the Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at or by mail or phone Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, 20201 800-368-1019, 800-537-7697 (TDD)

8 Complaint forms are available at 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.

9 Registered trademark of CareFirst of maryland , (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 d Yor b (Yoruba) t t l ko: k y s y n w f n n pa i ad j t f r.

10 Le n w n d t p t o s le n l ti gb gb s n w n j gb d ke kan. O ni t l ti gba w f n y ti r nl w n d r l f . w n m - gb gb d pe n mb f n t w l y n k d d nim w n. w n m r n le pe 855-258-6518 k o s d r n pas j r r t t a fi s f n l ti t 0. N gb t a oj kan b d h n, s d t o f a s so p m gbuf kan. Ti ng Vi t (Vietnamese) Ch : Th ng b o n y ch a th ng tin v ph m vi b o hi m c a qu v . Th ng b o c th ch a nh ng ng y quan tr ng v qu v c n h nh ng tr c m t s th i h n nh t nh. Qu v c quy n nh n c th ng tin n y v h tr b ng ng n ng c a qu v ho n to n mi n ph.