Currentblue cross blue shield - alabamaPolicy N/A

HEALTH MANAGEMENT REQUEST FOR CERTIFICATION

This document is a hospice certification request form for providers to submit clinical and administrative information to Blue Cross Blue Shield - Alabama for hospice eligibility/certification and related benefit verification. It collects patient, hospice, disease-specific clinical data, services provided, and hospice identification; notes certain eligibility exclusions and benefit rules.

Policy Summary

Payerblue cross blue shield - alabama

PolicyHEALTH MANAGEMENT REQUEST FOR CERTIFICATION

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective Date

Next Review Date

Key ActionProviders must complete the form with required patient, clinical, and hospice information and submit the physician order for Hospice with the certification request; attach clinical notes and recent labs.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — this is an administrative certification form with no policy changes.

1Form Type

2Explicit Exclusions

30Post-Certification Review (days)

Policy summary

This is a hospice certification request form used by hospice providers to request coverage and certification from Blue Cross Blue Shield - Alabama. It collects patient identifying information (name, address, telephone, DOB, contract number, caregiver and insurance), hospice provider identification (hospice name, address, provider number, telephone, fax, tax ID, hospice medical director), and requires submission of the physician order for Hospice with the certification request.

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The form captures disease-specific clinical evidence and services provided to support hospice eligibility, including primary and secondary diagnoses with ICD-10, place of care (Home Care, Inpatient Hospice, Respite), a checklist of services provided (e.g., SN, MSW, HHA, chaplain, therapist, MD/CRNP, DME, oxygen, BiPAP, wound care, IV fluids), and detailed disease-specific clinical criteria and recent labs (e.g., Karnofsky score, O2 sats, albumin, BUN/Cr, Hct/Hgb) to document decline and eligibility.

Operational and procedural notes: after initial certification a 30-day review is required unless otherwise specified by the case manager; the form instructs providers to fax the completed form and provides contact numbers for inquiries.

Document Metadata

PayerBlue Cross Blue Shield - Alabama

PolicyHealth Management Request for Hospice Certification Form

Policy CodeN/A

Effective Date

StatusCURRENT

Scope SummaryThis document is a hospice certification request form for providers to submit clinical and administrative information to Blue Cross Blue Shield - Alabama for hospice eligibility/certification and related benefit verification. It collects patient, hospice, disease-specific clinical data, services provided, and hospice identification; notes certain eligibility exclusions and benefit rules.

Eligibility and documentation requirements

Eligibility / Documentation Requirements

Form requests documentation and clinical criteria to support hospice certification; indicates non-eligible diagnoses and non-covered services:

Patient & Administrative Information: Patient information must be provided: name, address, telephone, DOB, contract number, primary/secondary diagnosis with ICD-10, start of hospice date, caregiver and insurance info

Refer to Patient Information section for exact fields

Place of Care and Services: Place of care indicated (Home Care, Inpatient Hospice, Respite inpatient/home) and services provided with frequency (SN, MSW, HHA, Chaplain, Therapist, MD/CRNP, DME, oxygen/BiPAP, IV fluids, wound care, etc.)

See PLACE OF CARE and SERVICES PROVIDED checkboxes

Disease-Specific Clinical Criteria: Disease-specific clinical information must be provided; check applicable disease and clinical boxes (examples include NYHA class 4; dyspnea at rest; unable to walk; CD4 count < 25; viral load > 100,000; O2 sat: max O2 support; Karnofsky < 40; PCO2 > 55; INR > 1.5; Albumin < 2.0; Creatinine clearance <10 ml/min; Serum Cr > 6.0; refractory ascites; dysphagia/unable to support life; etc.)Karnofsky < 40; CD4 < 25; Viral load > 100,000; PCO2 > 55; INR > 1.5; Albumin < 2.0; Cr clearance < 10 ml/min; Serum Cr > 6.0

Use the specific checkboxes in Disease-Specific Clinical Information to document eligibility findings

History, Progression, Labs & Vitals: History and progression of disease must be documented (attach clinical notes); recent labs (BUN/Cr, Albumin, Hct/Hgb) and vitals (BP, P, R, T, height, weight, BMI), Karnofsky score, and O2 saturations must be documented/attached

See History and Progression of Disease; Recent laboratory data and Vital signs fields

Medications & Hospice Coverage: List all medications with dosage and indicate whether each is covered by hospice (Y/N)

Medications (list all) table

Treatment Goals & DNR: Attestation whether patient no longer seeking aggressive treatment and desires symptom management/comfort care; DNR status must be indicated

Patient no longer seeking aggressive treatment; DNR signed and understood

Physician Order Submission: Submit physician order for Hospice with the request for certification (Ordering MD name and provider number required)

Ordering MD section: Submit physician order for Hospice with request for certification

Hospice Identification: Hospice identification required: hospice name, address, provider number, telephone, fax, tax ID, and hospice medical director name

See Hospice Identification and Certification section

Operational Review Note: After initial certification, a 30-day review is required unless otherwise specified by the case manager

Statement appears under Hospice name block indicating 30-day review requirement

Ineligible Diagnoses: Failure to Thrive and Generalized Weakness are not eligible diagnoses for benefit coverage

Explicit exclusion in Disease-Specific Clinical Information

Non-covered Benefit: Continuous Care is not a covered benefit and should not be requested as part of hospice benefits

Statement in Hospice Identification and Certification: Continuous Care is not a covered benefit

Threshold Summary

Karnofsky score< 40 (checkbox provided as clinical criterion)

CD4 count< 25 (checkbox provided as clinical criterion)

Viral load> 100,000 (checkbox provided as clinical criterion)

PCO2> 55 (checkbox provided as clinical criterion)

Albumin< 2.0 (checkbox provided as clinical criterion)

Creatinine clearance<10 ml/min (checkbox provided as clinical criterion)

Serum creatinine> 6.0 (checkbox provided as clinical criterion)

INR> 1.5 (checkbox provided as clinical criterion)

What providers must do

Documentation Required

Submit completed certification form and physician order

Complete the hospice certification form with all required patient, clinical, and hospice information and include the physician order for Hospice when submitting the certification request. Attach supporting clinical notes and recent laboratory data as indicated on the form.

Prior Authorization

Certification and 30-day review requirement

After the initial certification is completed, a 30-day review is required unless the case manager specifies otherwise.

Documentation Required

Do not include ineligible diagnoses

Do not submit Failure to Thrive or Generalized Weakness as the primary hospice diagnosis — these are not eligible diagnoses for benefit coverage.

Failure to Thrive
Generalized Weakness

Billing Rule

Continuous Care not covered

Continuous Care is not a covered hospice benefit and should not be requested as part of hospice benefits or on this certification form.

Documentation Required

Fax and inquiry contacts

Fax the completed form to the number below or call the listed inquiry numbers for assistance.

Fax: 205-402-9305
Birmingham: 205-733-7067
Outside Birmingham: 1-800-821-7231

Definitions and notes

Continuous Care is defined in the brief as a level of hospice care that is not a covered benefit per this form.

Contextual note: the form explicitly states that Continuous Care is not a covered benefit and should not be requested as part of hospice benefits on this certification form.

Document changes

CURRENTLatest

Current version of the hospice certification request form; no dated revisions provided.

Policy Summary

Payerblue cross blue shield - alabama

PolicyHEALTH MANAGEMENT REQUEST FOR CERTIFICATION

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective Date

Next Review Date

SourceLink

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