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
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(Amharic) -
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ìrànlw ní èdè r lf. Àwn m-gb
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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
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(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
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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
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Vous avez le droit d'obtenir gratuitement ces informations et de
l'aide dans votre langue. Les membres doivent
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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: