Use our new benefit request forms for non-Medicare case management

Case Management Skilled Nursing Facility Request Starting Jan. 1, 2017, when a Blue Cross Blue Shield of Michigan member with a non-Medicare Advantage commercial plan requests skilled nursing or long-term acute care hospital services that aren’t a standard benefit, our case managers will send new forms to treating providers.

The revised forms, shown at right, replace the Proposed Physician Treatment Plan/General Information Request, or PPTP/GI form. The new forms — based on InterQual^® Criteria — will help us review requests faster. You’ll no longer need to provide multiple pages of extensive clinical details, just complete the form in its entirety. However, if our case manager needs additional clinical data, we may request it from you.

Case Management Skilled Nursing Facility Request When a hospital case manager requests Blue Cross case management, our assigned case manager will send you the new form to submit for review.

Note: The process isn't changing, only the forms.

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.