Concurrent Review

Forms for DME and RX requiring Prior Authorization can be found at Providers.Bluekc.com and clicking on the Forms button on the login page.

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* Required Field

Enter Patient Information

  • Facility:
  • Patient First Name: *
  • Patient Middle Initial:
  • Patient Last Name: *
  • Date of Birth: *
  • Group ID: *
  • Date of Service/Admission Date: *
  • ICD-10 Diagnosis Codes: *
  • Diagnosis Codes must be 3-8 characters with NO decimals
    Codes must be 3 - 8 characters and no decimals.

* Required Field

Enter Provider Information

  • Provider ID OR NPI: *
  •  
    • I am an Admitting Physician
    • I am an Attending Physician
  • Admitting Physician's Name:
  • Admitting Physician's Address:
  • Admitting Physician's City:
  • Admitting Physician's State:
  • Admitting Physician's Zip:
  • Admitting Physician's Email Address:
  • Admitting Physician's Phone No:
  • Admitting Physician's Fax No:
  • Attending Physician's Name:
  • Servicing Attending's Address:
  • Attending Physician's City:
  • Attending Physician's State:
  • Attending Physician's Zip:
  • Attending Physician's Email Address:
  • Attending Physician's Phone No:
  • Attending Physician's Fax No:
  • Contact First Name: *
  • Contact Last Name: *
  • Contact Email Address:
  • Contact Phone No:
  • Contact Phone Ext:
  • Contact Fax No:
  • Recent abnormal lab: *
  • Include medication list.
  • Most recent typed progress note.
  • H&P if not sent with first update.

Barriers to Discharge: *

Pain level/treatment plan

Depression with treatment and/or Psych Consult: *

  • Yes
  • No

Available Support: *

Environment Concerns (i.e., stairs): *

Is there a need or plan for home Physical Therapy evaluation? *

  • Yes
  • No

Discharge Plan-anticipated discharge date/comments:

Please include follow up appointment(s):

Please attach relevant clinical documentation

Choose a file or files to attach (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







Physical Therapy Date: Date: Date:  
Bed Mobility  
Sit-Stand Transfers  
Bed/Chair/Wheelchair Transfers  
Weight Bearing Status  
Gait:
Distance/Assist/Device
 
Stairs  
Wheelchair Mobility  
S/D Sitting Balance  
D/D Standing Balance
Occupational Therapy Date: Date: Date:  
Feeding  
Grooming/Hygiene  
UB Dressing  
LB Dressing  
Bathing  
Tub/Shower Transfers  
Toileting  
Toilet Tranfers  
Endurance
Speech Therapy Date: Date: Date:  
Current Diet/Swallow  
Memory  
Cognition
Wound Date (initial): Date: Date:  
Description (location/appearance)  
Measurement  
Dressing Care  
Tx Plan  
Precautions-DME being used  
Wound Vac  
Dressing Frequency
  • Checking this box will send a copy of your form to the email address provided.

If you experience issues submitting this form, please print and fax it to (816) 995-1580.

Cancel

Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

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