Managed Long-Term Services and Supports Provider Area Service Form

This form is for Anthem HealthKeepers Plus members on behalf of HealthKeepers, Inc.

Provider name and doing business as per W-9:

TIN: NPI:

Please indicate below the type of services your agency provides. ☐ Home health ☐ Private duty nursing ☐ Personal care (skilled nursing visits) (hourly skilled nursing) ☐ Physical therapy ☐ Pediatric care ☐ Respite ☐ Speech therapy ☐ Ventilator care needs ☐ Service facilitator ☐ Occupational therapy ☐ Complex tracheostomy care ☐ Assistive technology Additional service(s):

Attestation: I hereby affirm that our agency is in compliance with the provider waiver requirements as established in the Department of Medical Assistance Services provider manuals available at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal and the following regulations: 12VAC30-120-900 through 12VAC30-120-995.

I also affirm that the service area information is reflective of our current service area capabilities and will need to be updated as modified by our organization’s capabilities.

Signature:

Printed name/title: Date: Telephone:

☐ Check here if you service Virginia statewide. If so, there is no need to proceed. If you do not service Virginia statewide, review the remainder of the document and check the applicable service areas by region.

☐ Central region — If you service all cities in the Central region, please check this box. County or ZIP Standard city County or ZIP Standard city independent city independent city (FIPS) (FIPS) ☐ Amelia (007) 23002 Amelia ☐ Lancaster (103) 22503 Lancaster ☐ Brunswick (025) 23868 Lawrenceville ☐ Lunenburg (111) 23952 Lunenburg ☐ Caroline (033) 22428 Bowling Green ☐ Mathews (115) 23109 Mathews ☐ Charles City 23030 Charles City ☐ Mecklenburg (117) 23917 Boydton (036) ☐ Chesterfield 23832 Chesterfield ☐ Middlesex (119) 23149 Saluda (041)

https://mediproviders.anthem.com/va HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. AVAPEC-1470-17 July 2017 Anthem HealthKeepers Plus Managed LTSS Provider Area Service Form Page 2 of 5

County or ZIP Standard city County or ZIP Standard city independent city independent city (FIPS) (FIPS) ☐ Colonial Heights 23834 Colonial Heights ☐ New Kent (127) 23124 New Kent (570) City ☐ Cumberland 23040 Cumberland ☐ Northumberland 22473 Heathsville (049) (133) ☐ Dinwiddie (053) 23841 Dinwiddie ☐ Nottoway (135) 23955 Nottoway ☐ Emporia (595) 23847 Emporia ☐ Petersburg (730) 23803 Petersburg City ☐ Essex (057) 22560 Tappahannock ☐ Powhatan (145) 23139 Powhatan ☐ Franklin City 23851 Franklin ☐ Prince Edward 23901 Farmville (620) (147) ☐ Fredericksburg 22401 Fredericksburg ☐ Prince George 23875 Prince George (630) City (149) ☐ Goochland (075) 23063 Goochland ☐ Richmond City 23220 Richmond (760) ☐ Greensville (081) 23867 Jarrett ☐ Richmond (159) 22572 Warsaw ☐ Hanover (085) 23069 Hanover ☐ Southampton 23837 Courtland (175) ☐ Henrico (087) 23238 Henrico ☐ Spotsylvania (177) 22553 Spotsylvania ☐ Hopewell (670) 23860 Hopewell ☐ Stafford (179) 22554 Stafford ☐ King and Queen 23085 King and Queen ☐ Surry (181) 23883 Surry (097) ☐ King George 22485 King George ☐ Sussex (183) 23884 Sussex (099) ☐ King William 23806 King William ☐ Westmoreland 22520 Montross (101) (193)

☐ Tidewater region — If you service all cities in the Tidewater region, please check this box. County or ZIP Standard city County or ZIP Standard city independent city independent city ☐ Accomack (001) 23301 Accomack ☐ Northampton 23347 Eastville (131) ☐ Chesapeake 23320 Chesapeake ☐ Poquoson (650) 23662 Poquoson (550) ☐ Gloucester (073) 23062 Gloucester ☐ Portsmouth (740) 23701 Portsmouth ☐ Hampton (650) 23630 Hampton ☐ Suffolk (800) 23432 Suffolk ☐ Isle of Wight 23430 Isle of Wight ☐ Virginia Beach 23450 Virginia Beach (093) (810) ☐ James City (095) 23185 Williamsburg ☐ Williamsburg 23186 Williamsburg (830) Anthem HealthKeepers Plus Managed LTSS Provider Area Service Form Page 3 of 5

County or ZIP Standard city County or ZIP Standard city independent city independent city ☐ Newport News 23601 Newport News ☐ York (199) 23690 Yorktown (700) ☐ Norfolk (710) 23501 Norfolk

☐ Northern/Winchester region — If you service all cities in the Northern and Winchester regions, please check this box. County or ZIP Standard city County or ZIP Standard city independent city independent city ☐ Alexandria (510) 22301 Alexandria ☐ Loudoun (107) 20175 Leesburg ☐ Arlington (013) 22201 Arlington ☐ Manassas City 20110 Manassas (153) ☐ Clarke (043) 22611 Berryville ☐ Manassas Park 20111 Prince William (153) ☐ Culpeper (047) 22701 Culpeper ☐ Page (139) 22835 Luray ☐ Fairfax City (600) 22030 Fairfax ☐ Prince William 22025 Manassas (153) ☐ Fairfax County 22003 Annandale ☐ Rappahannock 22747 Washington (059) (157) ☐ Falls Church 22040 Falls Church ☐ Shenandoah 22664 Woodstock (610) (171) ☐ Fauquier (061) 20186 Warrenton ☐ Warren (187) 22630 Front Royal ☐ Frederick (069) 22602 Winchester ☐ Winchester (840) 22601 Winchester

☐ Western/Charlottesville region — If you service all cities in the Western and Charlottesville regions, please check this box. County or ZIP Standard city County or ZIP Standard city independent city independent city ☐ Albemarle (003) 22901 Charlottesville ☐ Halifax (083) 24577 Nathalie ☐ Amherst (009) 24521 Amherst ☐ Harrisonburg 22801 Harrisonburg (660) ☐ Appomattox 24522 Appomattox ☐ Louisa (109) 23093 Louisa (011) ☐ Augusta (015) 24421 Staunton ☐ Lynchburg (680) 24504 Lynchburg ☐ Buckingham 23921 Buckingham ☐ Madison (113) 22727 Madison (029) ☐ Campbell (031) 24588 Rustburg ☐ Nelson (125) 22949 Lovingston ☐ Charlotte (037) 23923 Charlotte Ct. ☐ Orange ( 137) 22942 Orange House ☐ Charlottesville 22902 Charlottesville ☐ Pittsylvania (143) 24531 Chatham (540) Anthem HealthKeepers Plus Managed LTSS Provider Area Service Form Page 4 of 5

County or ZIP Standard city County or ZIP Standard city independent city independent city ☐ Danville (590) 24541 Danville ☐ Rockingham 22802 Harrisonburg (165) ☐ Fluvanna (065) 22963 Palmyra ☐ Staunton (790) 24402 Staunton ☐ Greene (079) 22973 Stanardsville ☐ Waynesboro 22980 Waynesboro (820)

☐ Roanoke/Alleghany region — If you service all cities in the Roanoke and Alleghany regions, please check this box. County or ZIP Standard city County or ZIP Standard city independent city independent city ☐ Alleghany (005) 24422 Clifton Forge ☐ Lexington (678) 24450 Lexington ☐ Bath (017) 24445 Hot Springs ☐ Martinsville (690) 24112 Martinsville ☐ Bedford (019) 24523 Bedford ☐ Montgomery 24068 Christiansburg (121) ☐ Botetourt (023) 24019 Hollins ☐ Patrick (141) 24171 Stuart ☐ Buena Vista 24416 Buena Vista ☐ Pulaski (155) 24301 Pulaski (530) ☐ Covington (580) 24426 Covington ☐ Radford (750) 24141 Radford ☐ Craig (045) 24127 New Castle ☐ Roanoke City 24012 Roanoke City (770) ☐ Floyd (063) 24091 Floyd ☐ Roanoke (161) 24179 Roanoke ☐ Franklin (067) 24151 Rocky Mount ☐ Rockbridge (163) 24472 Vinton ☐ Giles (071) 24134 Pearisburg ☐ Salem (775) 24153 Salem ☐ Henry (089) 24055 Bassett ☐ Wythe (197) 24382 Wytheville ☐ Highland (091) 24465 Monterey

☐ Southwest region — If you service all cities in the Southwest region, please check this box. County or ZIP Standard city County or ZIP Standard city independent city independent city ☐ Bland (021) 24315 Bland ☐ Norton (720) 24273 Norton ☐ Bristol (520) 24201 Bristol ☐ Russell (167) 24266 Lebanon ☐ Buchanan (027) 24614 Grundy ☐ Scott (169) 24251 Gate City ☐ Carroll (035) 24343 Hillsville ☐ Smyth (173) 24354 Marion ☐ Dickenson (051) 24228 Clintwood ☐ Tazewell (185) 24630 North Tazewell ☐ Galax (640) 24333 Galax ☐ Washington (191) 24210 Abingdon ☐ Grayson (077) 24348 Independence ☐ Wise (195) 24293 Wise Anthem HealthKeepers Plus Managed LTSS Provider Area Service Form Page 5 of 5

County or ZIP Standard city County or ZIP Standard city independent city independent city ☐ Lee (105) 24263 Jonesville