Anthem HealthKeepers Medicare-Medicaid Plan MMP 2026

1. Click ‘Get Form’ to open the Anthem HealthKeepers Medicare-Medicaid Plan MMP in the editor.
2. Begin by entering today’s date at the top of the form. This helps track when the request was made.
3. Fill in the provider return fax number to ensure that responses are sent back correctly.
4. In the Member Information section, clearly input the member's name, member number, date of birth, and address. Verify eligibility before proceeding.
5. Complete the Referring Provider Information by providing details such as name, contact information, and relevant provider numbers.
6. For Specialist Consults, enter the consultant's name, specialty, and contact details. Include diagnosis codes and any previous treatment history.
7. If applicable, fill out sections for maternity care or diagnostic studies with specific details regarding procedures and reasons for referral.
8. Attach any necessary clinical information to support medical necessity before submitting your completed form.

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