Blue ltch print 2026

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4.8 out of 5

30 votes

The document is an Initial Precertification Form for skilled nursing, long-term care hospital, or rehabilitation hospital services. It provides instructions for completing and submitting the form to request authorization for these services, along with sections for member and facility information, admission details, clinical status, treatment plans, and discharge goals. It also includes specific contact numbers for different member categories and emphasizes the need for using in-network ambulance providers.

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Click ‘Get Form’ to open the blue ltch print in the editor.
Begin with Section A, Member Information. Fill in the member's name, date of birth, and Blue Cross Blue Shield of MA member ID number. Ensure accuracy for smooth processing.
Proceed to Section B, Facility Information. Enter the facility referred to, its address, and confirm if it is contracted with local BCBS by selecting 'Yes' or 'No'. Include the facility's NPI and contact details.
In Section C, Admission Information, provide the anticipated admit date and requested number of days. Include details for both facility and acute case managers.
Move to Section D for Clinical Information. Document diagnosis, review of acute care admission, past medical history, and social history as required.
Complete Sections E through I by detailing clinical status/treatment, labs/diagnostics, current level of function/treatment, prior level of function/treatment, and discharge plan/goals.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (30 Votes)
2012	4.2 Satisfied (42 Votes)

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