Embed Size (px)
Citation preview
Complex surgery fee uplift request form
This form is designed to provide us with the information we need to assess eligibility for a surgical fee uplift.
Please complete all sections of the form and ensure that it is signed by a Bupa recognised consultant. We would appreciate it if the information you provide is typed and not handwritten.
We are unable to assess forms that are incomplete or do not have a valid signature. If we receive a form that is incomplete, we will contact the named consultant to ask them to resubmit the form with all the required information.
We use evidence-based best practice guidelines when making decisions about treatment eligibility for funding in line with members’ policies and hospital agreements. Please ensure that all sections are completed in full and you supply all necessary supporting information, as we are unable to contact other providers to obtain the information. We are unable to assess incomplete forms and this will delay our answer.
If you have any questions please contact us on 0345 755 3333. Lines are open 8am to 6pm Monday to Friday. We may record or monitor our calls.
Please return the completed form to us either by secure fax on: 01784 234 290
Or, if you would like to send the form by email please set up a secure route by emailing [email protected]. Please do not use unsecure email to send patient-identifiable data.
Section 1
About the patient
Miss
First name
Mrs Ms Mr Dr other (please state)
Last name
Date of birth
Address
D D M M Y Y Y Y
Postcode
Bupa membership number
Section 2
About the consultant and hospital
Name of requesting consultant
Specialty
Hospital name
Please confirm that you have explained to the patient about your fees and charges in writing in advance of their procedure (where possible)2:
No I have not let the Bupa patient know about
my fees/charges in writing my fees/charges
No, it is not possible to let the Bupa patient know about my fees/charges (please explain why below)
Yes, I have let the Bupa patient know about
2GMC Good Medical Practice: Financial & commercial dealings www.gmcuk.org/guidance/good_medical_practice/probity_financial_and_commercial_dealings.asp
BMA Good Billing Practice: A Guide for Private Practitioners, BMA 2009
Section 3
Pre-authorisation number
Procedure information
Reason for procedure(s)
Date of procedure D D M M Y Y Post-operative request Pre-operative request
Consultant who performed/will perform
the procedure (include speciality)
Narrative Closest
CCSD code
If the request is for two or more surgeons, please provide clinical rationale and outline which procedures will be performed by each surgeon.
Usual operating time for given codes
Anticipated/actual operating time
Normal Bupa Benefit Limit
Fee requested
Section 4
Clinical rationale for uplift request (continue on separate page if necessary)
Section 5
Declaration
I confirm that I have completed this form and that it is accurate to the best of my knowledge. I certify that the patient (or their representative) has given permission for this information to be provided to Bupa for the purposes described within this form.
Consultant’s signature
Consultant’s name (please print)
Consultant’s Bupa Provider Number
How would you prefer us to let you know whether funding is eligible
Telephone Fax Email Post
Date form completed M Y Y Y YD D M
Section 6
Additional documents
I confirm that the following have been provided to Bupa:
Operation notes Anaesthetic charts
Please ensure both documents are included as we are unable to review any surgical fee uplift requests without the documents listed above.
Bupa Health Insurance is provided by Bupa Insurance Limited. Registered in England and Wales No. 3956433 Bupa Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Arranged and administered by Bupa Insurance Services Limited, which is authorised and regulated by the Financial Conduct Authority. Registered in England and Wales No. 3829851. Registered office: Bupa House, 15-19 Bloomsbury Way, London WC1A 2BA. © Bupa 2015
