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

Enter Patient Information

Facility: *
Blue KC ID (Not SS#): *
- i
- i
- i
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 along with decimals

Codes must be 3 - 8 characters along with decimals.

* Required

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: *

Available Support: *

Environment Concerns (i.e., stairs): * Is there a need or plan for home Physical Therapy evaluation? *

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.

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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.

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.

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.

Concurrent Review

Enter Patient Information

Enter Provider Information

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