Fillable JOINT AND SPINE PROCEDURES AUTHORIZATION REQUEST FORM (Blue Cross Blue Shield of Michigan)

Fill Online, Printable, Fillable, Blank JOINT AND SPINE PROCEDURES AUTHORIZATION REQUEST FORM (Blue Cross Blue Shield of Michigan) Form

Use Fill to complete blank online BLUE CROSS BLUE SHIELD OF MICHIGAN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

JOINT AND SPINE PROCEDURES AUTHORIZATION REQUEST FORM (Blue Cross Blue Shield of Michigan)

On average this form takes 16 minutes to complete

The JOINT AND SPINE PROCEDURES AUTHORIZATION REQUEST FORM (Blue Cross Blue Shield of Michigan) form is 2 pages long and contains:

  • 0 signatures
  • 23 check-boxes
  • 55 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Blue Cross Blue Shield of Michigan forms online.

BROWSE BLUE CROSS BLUE SHIELD OF MICHIGAN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
JOINT AND SPINE PROCEDURES
AUTHORIZATION REQUEST FORM
Utilization management toll-free phone: 1-833-217-9670
Utilization management local phone: 313-908-6040
Utilization management fax: 313-879-5509
1 | P a g e
Today’s date and time:
Member name:
Provider contact name:
Date of birth:
Provider contact phone:
Member ID (including any alpha prefix):
Provider contact fax:
Health plan:
Provider name:
Notification method preference:
☐ Postal mail
☐ Fax
Please provide mailing address or fax number.
Provider TIN:
Provider NPI:
Practice/group name:
Provider physical address:
Notes:
Provider mailing address (if different):
Requested procedure:
Anticipated surgery date:
CPT/HCPCS or ICD procedure code(s):
Diagnosis code(s):
Facility setting:
☐ Inpatient hospital
☐ Outpatient
☐ Ambulatory surgical center
Facility name:
Facility contact name:
Facility TIN:
Facility contact phone:
Facility NPI:
Facility contact fax:
Facility physical address:
Facility mailing address (if different):
Patient’s height: __________
Patient’s weight: _________
Provider Office
JOINT AND SPINE PROCEDURES
AUTHORIZATION REQUEST FORM
Utilization management toll-free phone: 1-833-217-9670
Utilization management local phone: 313-908-6040
Utilization management fax: 313-879-5509
2 | P a g e
Does the patient have any of the following comorbidities? Select all
that apply.
o Diabetes that requires medication or insulin (Type I or Type II)
A1C Level:_________
o Hypertension requiring medication
o Previous cardiac event
o Congestive heart failure
o Dyspnea
o Current smoker within past 12 months
o History of severe COPD
o Dialysis
o Acute renal failure
o Ascites within past 30 days
o Steroid use for chronic condition
o Disseminated cancer
o None of the above
Patient’s activities of daily living (ADL) functional
status:
o Independent
o Partially dependent
o Totally dependent
What is the patient’s current health status?
o Normal healthy patient
o Mild or moderate disease that does not limit activity
(ex: controlled HTN or DM, mild obesity)
o Severe disease that limits activity (ex: controlled
CHF, history of MI, uncontrolled HTN or DM)
o Severe life-threatening disease (ex: symptomatic
CHF or COPD, renal failure, unstable angina)
Does the patient have psychosocial and/or substance use issues?
o Absent - no psychosocial and/or substance use issues
o Addressed – psychosocial and/or substance use issues present but addressed
Will any of the following be used?
o Allograft
o Autograft – patient’s own tissue
o Bone Morphogenetic Protein
o Stem cells
o None of the above
If requesting procedure code *20930, please indicate tissue type:
Vendor:____________________________________________
Name/type of product: _________________________________
Will a co-surgeon or assistant be utilized?
o Orthopedic
o Physician’s Assistant/Nurse Practitioner
o RN Surgical Assistant
o Other:__________________
o No planned co-surgeon or assistant
Other Products Intended to be Used:
Manufacturer:
Product line:
NOTE: Please include imaging reports, surgical plan and clinical documentation of ALL conservative therapies that
have been attempted as well as the duration of each type of conservative treatment.
Completed by:
Date:
*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2019 American Medical Association. All rights reserved.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

JOINT AND SPINE PROCEDURES AUTHORIZATION REQUEST FORM (Blue Cross Blue Shield of Michigan)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 12 October 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document