Anthem HealthKeepers Plus LTSS Authorization Request
This form is essential for providers to request long-term services and supports authorizations for Anthem HealthKeepers Plus. It covers new requests, changes, renewals, and cancellations for Medicaid services. Ensure to follow the guidelines carefully to avoid delays in authorization.
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How do I fill this out?
Filling out the LTSS Authorization Request Form requires accuracy and attention to detail. Start by gathering all necessary member information and details about the requested services. Review the instructions thoroughly to ensure a complete submission.
How to fill out the Anthem HealthKeepers Plus LTSS Authorization Request?
1
Collect member's health information and ID.
2
Select the type of request: new, change, renewal, or cancellation.
3
Fill in the service details and provider information.
4
Provide necessary attachments if required.
5
Submit the form via fax or designated method within the deadlines.
Who needs the Anthem HealthKeepers Plus LTSS Authorization Request?
1
Healthcare providers who wish to request new LTSS authorizations.
2
Members requiring long-term services and supports for Medicaid.
3
Administrators managing Medicaid services for enrollees.
4
Case managers coordinating care and services for members.
5
Clinicians assessing patient needs for ongoing services.
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What are the instructions for submitting this form?
Submit the completed form by faxing it to 844-864-7853. Alternatively, check with your provider manual for online submission methods. Always ensure the cover sheet includes a confidentiality notice, and submit requests promptly to prevent delays.
What are the important dates for this form in 2024 and 2025?
For 2024 and 2025, ensure to submit requests at least 30 days prior to the current authorization expiration date. Pay attention to any updates in the enrollment periods as dictated by Medicaid guidelines. This ensures continuous service availability for members.
What is the purpose of this form?
The purpose of the Anthem HealthKeepers Plus LTSS Authorization Request Form is to facilitate timely requests for long-term services and supports for Medicaid enrollees. By using this form, providers can ensure that necessary authorizations are secured for the continuation of care. This form also plays a vital role in documentation and compliance within healthcare regulations.
Tell me about this form and its components and fields line-by-line.
- 1. Request Type: Indicates whether the request is new, a modification, a renewal, or cancellation.
- 2. Date of Request: The date on which the service request is being submitted.
- 3. Member's HealthKeepers ID: Unique identifier for the member in the HealthKeepers system.
- 4. Requesting Provider Name: The name of the provider submitting the request.
- 5. Service Authorization Type: Specifies the type of long-term service being requested.
- 6. Diagnosis Code: The ICD-10 code representing the member's primary diagnosis.
What happens if I fail to submit this form?
Failing to submit this form could result in delays in receiving necessary services. If the form is incomplete or not submitted, providers risk having requests denied and thus affecting member care.
- Delays in Service: Authorization delays can lead to interruptions in essential member services.
- Denied Requests: Incomplete submissions may lead to requests being denied, requiring re-authorization.
- Non-compliance with Medicaid: Lack of timely submission can lead to compliance issues with Medicaid regulations.
How do I know when to use this form?
- 1. New Request: For initiating new authorization requests for services under Medicaid.
- 2. Renewal: To request continued authorization for existing services.
- 3. Change Request: For modifying an existing service authorization to reflect changes in needs.
- 4. Cancellation: To cancel an authorization when services are no longer needed.
Frequently Asked Questions
How do I submit this form?
You can submit this form by faxing it to the designated number or by using online submission options provided.
What information do I need to fill out?
You will need the member's ID, health details, and service request specifics to fill out the form.
Can I edit the PDF before submitting?
Yes, you can edit the PDF using PrintFriendly's editing tools before submitting.
How long does it take to process this request?
Standard requests may take up to five business days, while expedited requests can be processed within 72 hours.
What happens if I submit the form late?
If submitted late, the request will be reviewed based on the received date, and late days may be denied.
Is there a specific timeframe for submission?
Requests for new admissions must be submitted within 10 business days after the start of care.
Can I cancel an existing request?
Yes, you can cancel an authorization request by marking the appropriate section on the form.
Are attachments required?
Attachments may be required depending on the specifics of the service request.
What if I need assistance with the form?
Providers can contact support for help with filling out the form.
Is this form only for certain types of services?
This form is specifically for requesting long-term services and supports under Medicaid.
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