SG - LTSS Denial Summary Form

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SG - LTSS Denial - Instructions and Care Coordinator Information

Before starting this form, you will need the following:

To have access to, and be able to attach, the Individualized Care Plan (ICP)
To have access to accurate information from the health plan unit responsible for determining the LTSS being considered

Health Plan Name Required

Care Coordinator Name Required

Care Coordinator Phone Number Required

Care Coordinator Email Address Required

Enrollee's MassHealth ID (if known)