Guideline UpdatesHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsNovember 30, 2023

Legally Responsible Individual forms change

Please note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc.

The Legally Responsible Individual (LRI) Extraordinary Justification form (DMAS 95B) is required for parents or stepparents providing services for their minor children or spouse.

Beginning March 1, 2024, DMAS requires that all service facilitators and agency providers send form DMAS 95B directly to the member’s health plan.

This form should be delivered to the member’s care coordinator via secure e-mail or CC fax line (866-920-4097). If the name of the member’s care coordinator is not known, note this on the cover sheet and send to the fax line.

Please note that transmissions for consumer directed members must also include an updated Employer Agreement form.

If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at 800-901-0020.

HealthKeepers, Inc. is an independent licensee of the Blue Cross Blue Shield Association. Anthem HealthKeepers Plus, offered by HealthKeepers, Inc., is a health plan that contracts with the Virginia Department of Medical Assistance Services to provide Medicaid benefits to enrollees. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

VABCBS-CD-044318-23