Get Ltc Cto Request Form

Filling out the LTC CTO Request Form online is an important step for Long-Term Care Pharmacies seeking exceptions for claims submitted beyond the allowed time frame. This guide will walk you through each section of the form, providing clear instructions to ensure your request is completed accurately.

Follow the steps to successfully complete the LTC CTO Request Form.

1. Press the ‘Get Form’ button to access the LTC CTO Request Form online and open it in an editable format.
2. Enter the Pharmacy NPI number in the designated field. This number is essential for identifying your pharmacy in the claims process.
3. Provide the Date of Service (DOS) in the specified format. This date is critical as it marks the start of the 90-day submission window for claim exceptions.
4. In the Permitted Exceptions section, clearly indicate the relevant exception (A, B, or C) that corresponds with your claim situation. Review the descriptions provided earlier to select the appropriate option.
5. Complete the Pharmacy Name and Contact Information fields, including phone number and address. This contact information is vital for follow-up communication regarding your request.
6. In the signature area, confirm your understanding and agreement with the terms by signing your name as a duly authorized officer of the pharmacy. Fill in the title and date of signature to complete this section.

Complete your LTC CTO Request Form online today to ensure timely processing of your claims.