Anthem HealthKeepers Plus LTSS Authorization Request Form
This form is used to request long-term services and supports (LTSS) under Anthem HealthKeepers Plus. It details the procedures for submitting service authorizations and associated requirements. Health care providers must adhere to the guidelines for timely submissions to ensure member eligibility.
Edit, Download, and Sign the Anthem HealthKeepers Plus LTSS Authorization Request Form
Form
eSign
Add Annotation
Share Form
How do I fill this out?
To fill out the LTSS Authorization Request Form, start by checking the appropriate request type. Next, provide the necessary member information and the requested service details. Ensure all sections are completed accurately to avoid delays in processing your authorization.
How to fill out the Anthem HealthKeepers Plus LTSS Authorization Request Form?
1
Identify the type of request: new, change, renewal, or cancel.
2
Enter member details including ID number and date of birth.
3
Fill in the requesting and referring provider names.
4
Select the LTSS service authorization type and treatment setting.
5
Provide contact information and any necessary attachments.
Who needs the Anthem HealthKeepers Plus LTSS Authorization Request Form?
1
Healthcare providers seeking authorization for LTSS services.
2
Case managers who handle patient care services and need funding authorization.
3
Members of Anthem HealthKeepers Plus who require ongoing care and services.
4
Social workers coordinating long-term care for clients.
5
Billing departments needing to submit claims for LTSS services.
How PrintFriendly Works
At PrintFriendly.com, you can edit, sign, share, and download the Anthem HealthKeepers Plus LTSS Authorization Request Form along with hundreds of thousands of other documents. Our platform helps you seamlessly edit PDFs and other documents online. You can edit our large library of pre-existing files and upload your own documents. Managing PDFs has never been easier.
Edit your Anthem HealthKeepers Plus LTSS Authorization Request Form online.
You can easily edit this PDF on PrintFriendly by opening the file in our editor. Adjust any text or fields that need to be changed directly within the document. Once done, you can download the updated version for your records.
Add your legally-binding signature.
Signing this PDF on PrintFriendly is straightforward. After editing the file, you can use our signature feature to add your electronic signature. Simply select the area where you want to sign and follow the prompts to complete the process.
Share your form instantly.
With PrintFriendly, sharing PDFs is now easier than ever. Once you've completed your edits, you can click the share option to send the file through email or social media. This feature helps you quickly distribute essential documents to your colleagues or clients.
How do I edit the Anthem HealthKeepers Plus LTSS Authorization Request Form online?
You can easily edit this PDF on PrintFriendly by opening the file in our editor. Adjust any text or fields that need to be changed directly within the document. Once done, you can download the updated version for your records.
1
Open the PDF file in the PrintFriendly editor.
2
Select the text or field you wish to edit.
3
Make necessary changes to the content.
4
Review all edits for accuracy.
5
Download the edited PDF.
What are the instructions for submitting this form?
To submit the LTSS Authorization Request Form, fax the completed document to 844-864-7853. Ensure that all attached documentation, such as previous authorizations, is included and clearly marked. You may also choose to submit the form online through the Anthem providers portal for ease and tracking.
What are the important dates for this form in 2024 and 2025?
For the year 2024, it is crucial to submit LTSS requests at least 10 days prior to service start dates. In 2025, similar timelines should be followed to ensure all member needs are met timely. Awareness of these dates helps maintain uninterrupted care services.
What is the purpose of this form?
The Anthem HealthKeepers Plus LTSS Authorization Request Form serves as a structured method for healthcare providers to obtain authorization for long-term services and supports. This form is essential in ensuring that all required information for service delivery is correctly conveyed. By adhering to its guidelines, providers can facilitate timely approval of necessary services for members.
Tell me about this form and its components and fields line-by-line.
- 1. Request Type: Select whether the request is new, change, renewal, or cancel.
- 2. Date of Request: Provide the submission date in MM/DD/YYYY format.
- 3. Review Type: Indicate the type of review relevant to the request.
- 4. Member ID Number: Enter the member's HealthKeepers, Inc. ID number.
- 5. Member's Date of Birth: Provide the date of birth of the member.
- 6. Requesting Service Provider: Name and contact information for the provider making the request.
- 7. LTSS Service Authorization Type: Select the applicable type of service requested.
- 8. Treatment Setting: Specify where the services will be provided.
- 9. Primary ICD-10 Diagnosis Code: The diagnosis code that corresponds with the member's health condition.
- 10. Contact Information: Provide details on how to reach out for further information.
What happens if I fail to submit this form?
Failure to submit the LTSS Authorization Request Form can lead to delays in service approval and disruption in care for the member. All necessary services may not be initiated, leading to potential gaps in care management. It is vital to timely submit all requests to avoid unnecessary complications in service provision.
- Delays in Care: Without approved services, members may experience delays in receiving necessary care.
- Gaps in Service: Care continuity may be interrupted, affecting member health outcomes.
- Financial Implications: Delays can lead to potential financial issues for service providers and members.
How do I know when to use this form?
- 1. New Admissions: When admitting a new member requiring LTSS.
- 2. Change in Service Needs: If the member has changes in their care requirements.
- 3. Renewal of Services: To extend existing service authorizations that are about to expire.
- 4. Cancellation of Services: If a member no longer requires certain services.
- 5. Retrospective Reviews: For reviewing services provided in the past for eligibility.
Frequently Asked Questions
How do I submit my LTSS Authorization Request Form?
You can submit the completed form via fax at 844-864-7853 or through the designated online submission portal.
What if I need to cancel a request?
To cancel a request, simply check the cancel box on the form and provide the necessary member details.
What should I do if my request is denied?
If your request is denied, you have the right to appeal, and more information will be provided with your denied request.
Can I submit multiple requests at once?
Yes, you can submit multiple requests by completing a separate authorization request form for each one.
How long does it take to process the request?
Standard requests can take up to five business days, while expedited requests may take up to 72 hours.
What if I forget to include a required attachment?
If your form is submitted without required attachments, it may result in delays or a return of the form for completion.
Is there a specific deadline for submitting requests?
Requests for new admissions must be submitted within 10 business days of the start of care.
How can I track the status of my request?
You may contact the provider support line for updates on the status of your authorization request.
What if I need to make changes to my request after submission?
You will need to submit a change request form as per the instructions provided in the document.
Where can I find more information about LTSS services?
Additional information can be found on the Anthem website or by contacting customer support.
Related Documents - LTSS Authorization Request
Preparticipation Physical Evaluation Form
The Preparticipation Physical Evaluation Form is used to assess the physical health and fitness of individuals before they participate in sports activities. It covers medical history, heart health, bone and joint health, and other relevant medical questions.
Health Insurance Tax Credits Guide 2015
This document provides a comprehensive guide on health insurance and premium tax credits for the 2015 tax year. It explains the tax filing rules, eligibility criteria, and detailed instructions for claiming and reporting premium tax credits. Essential for individuals who bought health insurance through the ACA Marketplaces.
TSP-77 Partial Withdrawal Request for Separated Employees
The TSP-77 form is used by separated employees to request a partial withdrawal from their Thrift Savings Plan account. It includes instructions for completing the form, certification, and notarization requirements. The form must be filled out completely and submitted along with necessary supporting documents.
Ray's Food Place Donation Request Form Details
This file contains the donation request form for Ray's Food Place. Complete the general information section and follow the guidelines to submit your donation request at least 30 days in advance. The form includes fields for organization details and donation specifics.
Health Provider Screening Form for PEEHIP Healthcare
This file contains the Health Provider Screening Form for PEEHIP public education employees and spouses. It includes instructions on how to fill out the form for wellness program participation. The form collects personal, medical, and screening details to assess wellness.
Common Law Marriage Declaration Form for FEHB Program
This form is used to declare a common law marriage for the purpose of enrolling a spouse under the Federal Employees Health Benefits (FEHB) Program. It requires personal details, marriage information, and additional documentation. Submission instructions and legal implications are included.
Application for Certified Copy of Birth Certificate
This form is used to request a certified copy of a birth certificate from the Clerk of Court Office. It includes details about the applicant, the person named on the certificate, and requires a photo ID and the correct fee. This form is only for walk-in services.
Torrance Memorial Physician Network Forms for Patients 18+
This file contains important forms for patients 18 years and older registered with Torrance Memorial Physician Network. It includes patient registration, acknowledgment of receipt of privacy practices, and financial & assignment of benefits policy forms. Complete these forms to ensure your medical records are up-to-date and to understand your financial responsibilities.
Texas Automobile Club Agent Application Form
This file is the Texas Automobile Club Agent Application or Renewal form, which must be submitted within 30 days after hiring an agent. The form includes fields for agent identification, moral character information, and requires signature from both the agent and an authorized representative of the automobile club. Filing fees and submission instructions are also provided.
Sterile Dressings for Wound Care
This file provides detailed information about Xeroform and oil emulsion dressings used for various types of wounds. It includes product descriptions, indications for use, and information on sizes and quantities. Essential for medical professionals dealing with wound care.
CERTIFICATION OF MISSING OR LOST RECEIPT Form
This file is a Certification of Missing or Lost Receipt form that must be completed when the original receipts for expenses are not available. It outlines the necessary expenses which can be claimed, and describes the process for certifying those expenses. Complete this form to ensure compliance with travel regulations.
Ohio Civil Service Application Form for State Agencies
This is the Ohio Civil Service Application form for state and county agencies. It contains sections for personal information, education, employment history, and certifications. Ensure all information is filled out accurately to be considered for state employment.