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Valley Health Plan

Authorizations and referrals

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Below are authorization forms for VHP providers.  

Click on each (+) sign below.

Treatment authorization request form (TAR)​

Please clearly identify the service requested and the medical justification.  

The following information is required:

  • Diagnosis (ICD-10)
  • Service Request (CPT-4)
  • Number of visits requested
  • Reason the service is medically necessary, including documentation (such as H&P and progress notes)
  • Name of rendering provider requested
  • Name of referral provider submitting the request
  • Name of Member and Member's VHP ID number

If the Authorization Request Form (TAR) is not fully completed, the UM staff will request the needed information.  If the additional information is not provided within 10 working days, the request will be closed.  If the request has been closed, a new Authorization Request Form must be submitted to UM prior to performing services.

Please fax completed Authorization Request Form (TAR) to (408) 885-4875.

Valley Health Plan (VHP) contracts with Primary Care Physicians (PCPs) and Plan Providers who are responsible to provide and coordinate Covered Services or Benefits for your patient.. Except in the case of Emergency Services, Urgently Needed Services, or if VHP has Prior Authorized services, patients must receive all of their care from these VHP Plan Providers. If you provide services and are not in the VHP Network without Prior Authorization, your patient may be responsible for the charges.

Link to VHP's Prior Authorization Guidelines

VHP​ requires prior authorization for all post stabilization care. Effective immediately, please be advised that the number to call 24hrs per day/7 days per week is (855) 254-8264.

Any call to any phone number other than (855) 254-8264​ does not constitute notice of patient admission or request for post stabilization care.

A fax about a patient admission or request for transfer does not constitute notice of this request either.  This request must come via phone call to (855) 254-8264.

Prior Authorization Guidelines

If you have any questions or need additional help please contact Provider Relations at (408) 885-2221 or our use our online Contact Us Form.