Assertive Community Treatment (H0040) Continued Stay Service Authorization Request Form
A Medicaid service authorization request form for continued stay of Assertive Community Treatment (H0040) for Anthem HealthKeepers Plus members; captures provider, clinical, treatment progress, care coordination, medication update, discharge planning and attestation information required to justify continued services.
No material clinical or coverage changes — form template for continued stay authorization only.
Policy snapshot & scope
This form is a Medicaid service authorization request template for continued stay of Assertive Community Treatment (H0040) for Anthem HealthKeepers Plus members. It captures required provider and member identifiers, initial ACT admission date and per‑diem units, clinical information (diagnoses, medication updates), treatment progress documentation (ISP, CNA, addendum), care coordination, recovery/discharge planning, and LMHP attestation needed to justify continued services.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.