LTACH Fax Assessment Form - Blue Cross Blue Shield of Michigan 2026

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4.8 out of 5

55 votes

The document is a fax assessment form for Medicare Plus Blue SM PPO, specifically for Long-Term Acute Care Hospitals (LTACH). It outlines the process for precertification and recertification requests, including required patient information, clinical details, and treatment plans. The form must be completed by licensed clinical personnel and submitted to the appropriate contacts for processing. It emphasizes the importance of legibility, completeness, and timely submission of therapy notes to ensure proper authorization and payment.

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Click ‘Get Form’ to open the LTACH Fax Assessment Form in the editor.
Begin by filling out the 'Patient Information' section. Enter the patient's name, date of birth, address, and policy number. Ensure all information is legible.
Proceed to 'Admission Demographics'. Fill in the admission date, number of days requested, and facility details including name, NPI number, and contact information.
In the 'Current Clinical Information' section, provide vital signs such as blood pressure and heart rate. Include any relevant medical history and treatments administered.
Complete the 'Discharge Plans' section by indicating where the patient will reside post-discharge and any necessary assistive devices.
Review all fields for completeness. If a field does not apply, enter 'N/A'. Incomplete forms will be returned unprocessed.

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See more LTACH Fax Assessment Form - Blue Cross Blue Shield of Michigan versions

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Versions	Form popularity	Fillable & printable
2022	4.8 Satisfied (55 Votes)
2020	4.4 Satisfied (134 Votes)
2020	4.7 Satisfied (51 Votes)
2020	4.3 Satisfied (26 Votes)
2020	4.2 Satisfied (36 Votes)
2020	4.8 Satisfied (101 Votes)
2020	4.8 Satisfied (261 Votes)
2020	4.8 Satisfied (117 Votes)
2020	4.8 Satisfied (247 Votes)
2019	4.8 Satisfied (130 Votes)
2019	4.8 Satisfied (54 Votes)
2019	4.8 Satisfied (51 Votes)
2019	4.8 Satisfied (142 Votes)
2019	4.8 Satisfied (35 Votes)
2019	4.8 Satisfied (171 Votes)

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What is the payer ID for Blue Cross complete Michigan?

If youre interested in receiving electronic payments and remittance from Blue Cross Complete, enroll now at changehealthcare.com* and select Blue Cross Complete Michigan (payer ID: 32002) as your receiver.

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Fax requests to 1-877-325-5979.

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