Long-Term Services and Supports Waiver Forms

Family Health Network (FHN) has teamed up with Community Care Alliance of Illinois (CCAI) to provide care coordination services for Long-Term Services and Supports (LTTS) waiver recipients. CCAI, a subsidiary of FHN, is a not-for-profit organization that provides comprehensive, person-centered care locally for seniors and persons with disabilities.

Below you will find the resources you need to provide care to LTTS qualifying members.

                           What is a Waiver                               

                           LTSS Handbook                              

                        LTSS Presentation                              

                   LTSS Provider Billing Codes                  

                   LTSS Authorization Form                        

              Waiver Service Plan Authorization             

                Waiver Service Plan Example                   

Home & Community Service Sample Claim Form

   Supportive Living Facility Sample Claim Form   

Family Health Network Long-Term Services and Supports

New! LTSS providers can now register with the Medical Electronic Data Interchange (MEDI) system to verify MCO eligibility. Click the link below to visit the toolbox and learn how.


If you have questions about this web application please contact HFS at:
Network Services: 1-800-366-8768
HFS E-Mail: This email address is being protected from spambots. You need JavaScript enabled to view it.