Fillable Printable Sample Altcs Authorization Letter

Sample Altcs Authorization Letter

Arizona Health Care Cost Containment System

Fee-For-Service Provider Manual

Exhibit 21-1

SAMPLE ALTCS AUTHORIZATION LETTER

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

Douglas A. Ducey Thomas J. Betlach

Governor Director

October 1, 2015

654321

PROVIDER NAME

PROVIDER ADDRESS

CITY, STATE ZIP

CORRESPONDENCE REQUEST NUMBER: 314748 LTC PA LTR (PROVIDER APPROVAL)

LONG TERM CARE KEY INFORMATION: A12345678199

TO PROVIDER NAME:

THIS IS YOUR AUTHORIZATION CONFIRMATION FOR THE SERVICE(S) WHICH

REQUIRE AUTHORIZATION FROM THE ARIZONA LONG-TERM CARE SYSTEM (ALTCS)

ADMINISTRATION. THESE SERVICES HAVE BEEN APPROVED. RECEIPT OF THIS

NOTIFICATION IS NOT A GUARANTEE OF PAYMENT.

PROVIDER ID/NAME : 654321 (PROVIDER NAME)

RECIPIENT ID/NAME :A123456789 (EARP, WYATT DOB: 10/01/66 SEX: M)

RECIPIENT DATE OF BIRTH : 10/01/66

SERVICE CODE : T1019 (PERSONAL CARE SERVICES, PER 15 MINUTES)

DIAGNOSIS CODE : R68.89

SERVICE DATE FROM : 09/22/2015

SERVICE DATE THROUGH : 09/26/2015

UNITS APPROVED : 48

CASE MANAGER ID : 999999

CASE MANAGER NAME : LAST NAME, FIRST NAME

CASE MANAGER PHONE NUMBER : 5209991234

NOTE: THE AUTHORIZATION (PA) NUMBER HAS BEEN ELIMINATED. NO PA NUMBER

IS REQUIRED ON THE CLAIM FORM. RECEIPT OF THIS NOTICE NOW SERVES AS

PROOF THAT AUTHORIZATION WAS PROVIDED BY THE CASE MANAGER FOR

SERVICE(S) TO BE RENDERED.

BILLING QUESTIONS SHOULD BE DIRECTED TO THE AHCCCS CLAIMS CUSTOMER SERVICE

UNIT AT (602) 417-7670 option #4 OR 1-800-794-6862.

ANY QUESTIONS PERTAINING TO THE SERVICE(S) DELIVERED TO AN ALTCS

RECIPIENT SHOULD BE DIRECTED TO THE ACTUAL CASE MANAGER WHO REQUESTED

THE SERVICE(S)

SINCERELY,

AHCCCS ADMINISTRATION