CurrentAnthem HealthKeepers PlusPolicy N/A

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.

Policy Summary

PayerAnthem HealthKeepers Plus

PolicyAssertive Community Treatment (H0040) Continued Stay Service Authorization Request Form

Policy CodePolicy N/A

Change TypeForm/Documentation (informational)

Effective Date

Next Review Date

Key ActionProviders must complete and submit the continued stay authorization form including ISP, CNA, addendum/progress notes, medication updates, care coordination, and recovery/discharge planning to request approval of continued ACT services.

POLICY UPDATE CHANGES

No material clinical or coverage changes — form template for continued stay authorization only.

1Form for H0040 continued stay

MultipleRequired documentation elements

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.

Key facts

PayerAnthem HealthKeepers Plus (HealthKeepers, Inc.)

Policy / FormAssertive Community Treatment (H0040) Continued Stay Service Authorization Request Form

Document statusCURRENT

Scope summaryA 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.

Form for H0040 continued stay1

Required documentation elementsMultiple