inpatient Form

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Inpatient Authorization Request Instructions: All fields in this form are required unless otherwise indicated (optional / applicable). If not completed in full, expect a delay in response. Effective Jan. 1, 2025, Blue Cross Blue Shield of North Dakota (BCBSND) providers must use the Availity Essential Provider Portal. Faxes and phone calls for preservice precertification requests will no longer be accepted unless BCBSND gives approval due to system issues. Providers outside of North Dakota without electronic access should fax this form along with clinical support records to 701-277-2971. Questions? Call BCBSND UM at 800-952-8462. If providers are unable to use Availity to submit photos or for member submitted requests, please mail request and/or photos to: BCBSND Attn: Utilization Management 4510 13th Ave. S. Fargo, ND 58121 Member Information Patient First Name Patient Last Name Patient Date of Birth Member ID (including alpha-numeric prefix) Relationship to Subscriber: Self Spouse Child Other Service Information–Inpatient Service Type (Select One) If request is for outpatient services, please utilize Outpatient Authorization Request Form. Medical Surgical Transplant Psychiatric Substance Use Place of Service (Select One) Inpatient Hospital Inpatient Rehab Substance Use (3.7) Residental Treatment Center Inpatient Hospice Transitional Care Unit (TCU) Long Term Care Facility Swing Bed Skilled Nursing Facility Inpatient Hospital Detox Acute Medical Inpatient Rehab Facility Request Type (Select One) Initial (Complete Initial Service Information Section) Concurrent (Complete Concurrent Service Information Section) Initial Service Information Start of Care Date End of Care Date (If applicable) Page 1 of 4 Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association.

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Concurrent Service Information Start Care Date Previously Approved Services Start Date of Concurrent Care Request Authorization (AUTH-) number of previous request Diagnosis Diagnosis Code(s) 1 Required (Please use additional page if more ICD-10-CM codes are required) Code (ICD-10-CM) Description Code (ICD-10-CM) Description Code (ICD-10-CM) Description Code (ICD-10-CM) Description Procedure Code Procedure Code(s) (CPT/HCPCS, Required for Surgical Request. Please use additional page if more CPT/HCPCS are requested.) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Page 2 of 4

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Provider Information Requesting Provider First Name Requesting Provider Last Name Fax Number (Required) Specialty/Taxonomy Code (Optional) TIN (Optional) NPI Address Line 1 Address Line 2 (Optional) City State Zip Servicing Provider/Servicing Facility Information Service Provider First and Last Name or Facility Name Phone Number (Required) Fax Number (Required) NPI TIN (Optional) Address Suite City State Zip Completion Information Completed by Information Completed by Name (Required) Completed by Contact Phone Number (Required) Today’s Date Contact for Additional Questions Additional Contact Name Additional Contact Phone Number Additional Codes If Needed Diagnosis Code(s): 1 Required Code (ICD-10-CM) Description Code (ICD-10-CM) Description Code (ICD-10-CM) Description Page 3 of 4

BND-22-0169669 • 2-26 Additional Codes If Needed Procedure Code(s) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units) Code (CPT/HCPCS Description Quantity Requested Quantity Type (Days/Units) Page 4 of 4