Forms and Resources

The Forms and Resources page is designed to make it easier for VHP members to file a claim, appeal a denial of benefits, and learn more about their coverage. If you do not find what you need on this page, you may contact VHP's Member Services Department at 1.888.421.8444.

 

Plan Information

The Member Forms section provides information and links to forms that VHP Members might need to use to help us give you the best care.

Mom with Daughters in Park

     

    The Authorization of Use and/or Disclosure of Protected Health Information form is used to grant permission to a person(s) you designate to view your medical records, such as your doctor, health care provider, or lawyer.  When you complete and sign this form, health information about you will be released as you have indicated on the form. 

    Authorization for Use and/or Disclosure of Protected Health Information Form

     

     

    The Authorized Representative Form (AOR) is used by members who want to select a person to communicate with Valley Health Plan (VHP) on their behalf about appeals and grievances. When you choose a personal representative, that person can make decisions for you in most healthcare matters and can use, receive, and disclose your Protected Health Information (PHI). 

    VHP Authorized Representative Form

     

    The Coordination of Benefits and Information Form is required to be filled out if you or your dependent(s) have, or are entitled to other group health insurance, including Medicare. It is required by California law that you provide VHP with information about any other health insurance coverage that you care for yourself and/or your dependents. 

    VHP Coordination of Benefits Information Form

     

    A dependent child who is incapable of self-support due to a continuously disabling illness or injury may be continued as a family member on the parent’s Valley Health Plan contract. Physically or mentally handicapped Eligible Dependent(s) who is incapable of sustaining employment and is dependent upon you for support and maintenance may continue Coverage if the child was handicapped on the day before reaching age 26. The child can be covered under the Plan through age 25 or until the child recovers from the handicap or the date the child is no longer chiefly dependent on you for support and maintenance.

    Dependent Disability Certification Form

     

    We encourage our Members to contact us first to resolve any concerns about your care or benefits.  However, Members wishing to file a Grievance about any aspect of the services provided by the Valley Health Plan (VHP) may do so by following the Grievance and Appeals process.

    A Grievance can be filed on your behalf by a Member Services Advocate or you can complete a Grievance Form on your own and submit it to Valley Health Plan (VHP).  Grievance forms are available in three languages through VHP, at your provider's office, and by using the links below

     VHP Member Grievance and Appeal Form - English

    VHP Member Grievance and Appeal Form - Spanish

    VHP Member Grievance and Appeal Form - Vietnamese

    VHP Member Grievance and Appeal Form

     

    The Medical Claim Reimbursement Form includes information needed to review a Member's reimbursement request, preventing delays in the review process.  It also acts as a Release of Information form which includes a signature in the case a member has not submitted any medical record(s) needed to complete the review. 

    Members can file a Medical Claim Reimbursement Form within ninety (90) days of the date of service if you received claims or bills from a provider for services with a balance due and/or to request reimbursement for services received that were not able to be billed to VHP and had to be paid out of pocket such as:

    • Urgent Care & Emergency Services when out of the Valley Health Plan (VHP) network
    • Prescription Drugs for the above stated or when in-network and VHP network pharmacies are closed

    Medical Claim Reimbursement Form

    Formulario de Reembolso por un Reclamo Medico

    Mẫu Đơn Yêu Cầu Bồi Hoàn Y Phí

     

    The Pharmacy Reimbursement Form includes information needed to review a Member's reimbursement request for covered prescriptions and medications that the Member had to pay for out-of-pocket  at a pharmacy in the United States for the following reasons:

    • You did not have your ID card at the time of purchase
    • You were charged for medication received during an Urgent/Emergent Visit
    • You were administered a Medicare Part D covered vaccine at your doctor’s office
    • Primary coverage is with another insurance carrier. (Coordination of Benefits)

    Prescription Reimbursement Form

    The Foreign Prescription Reimbursement Form includes information needed to review a Member's reimbursement request for covered prescriptions and medications that the Member had to purchase outside of the United States. Reimbursement will be made to the Cardholder unless otherwise stated. Be sure the address you provide is a secure location to mail the check. VHP and Navitus are not responsible for lost or stolen checks.

    Foreign Prescription Reimbursement Form

     

    VHP Members choosing to participate in any of our fitness classes offered by the Health Education Department, both in-person and online, must fill out the Release and Waiver of Liability for Fitness Classes before they can participate.  

    Find out the classes currently are being offered, times, and locations on the VHP Health Education page. 

    Release and Waiver of Liability for Fitness Classes Form

    Plan Information

    The Plan Information section is where you will find information to help you get the most out of your health coverage plan whether it is an Employer Group, Covered California, or Individual and Family Plan.

    Same Sex Couple Eating Dinner with Son

       

      An Advance Health Care Directive is a formal document, signed by you in advance of a severe illness or injury, which will guide your physician(s) when providing treatment. Notwithstanding this document, you still have the right to make medical and other health care decisions for yourself so long as you can give informed consent regarding the particular decision. As long as you can speak for yourself, Plan Providers will honor your wishes. But, if you become so incapacitated that you cannot make an informed decision, this directive will guide your health care treatment based on the directions you set out in the Advance Health Care Directive.

      VHP Advance Health Care Directive 

      Valley Health Plan affirms That:

      1. Utilization Management decision making is based only on appropriateness of care and service and existence of coverage.
      2. The organization does not specifically reward practitioners or other individuals for issuing denials of coverage.
      3. There are no financial incentives for Utilization Management decision-makers.

      VHP offers a no cost, innovative Autism Care Management Program designed to support families taking care of a child with Autism Spectrum Disorder (ASD). Program care managers work with parents to deliver one-on-one support, prioritize care issues, and address any barriers that are obstacles to the family or their child receiving necessary health care services.

      The VHP care manager serves as the primary point of contact for families and can answer questions or address any problems the family is experiencing in making sure their child’s health care needs are met. VHP’s care managers are ASD specialists with the experience and understanding to help families living with a developmental disorder.

      Through the Autism Care Management Program families develop a relationship with their care manager that allows them to function as an extension of their health care team. This relationship helps to ensure that families get coordinated support in alignment with the family’s other doctors and specialists.

      Families with a child with an ASD diagnosis are contacted by one of our care managers after becoming a VHP member or when a current member receives an ASD diagnosis. If you are interested in finding out more about VHP’s Autism Spectrum Disorder Care Management Program, please call 1.888.863.7586 (toll-free)

      Is Your Information Up-to-Date?

      It is very important that VHP has your correct address and phone number on file. We want to make sure you receive our important mailings about additions or changes to benefits, providers/networks, or tools to help you maintain your overall health.

      If your information has changed, please call the number that applies to your coverage:

      Employer Group Plan Members

      Your Human Resources Department

      Covered California Plan Members

      Covered California Service Center
      1.800.300.1506

      Individual & Family Plan Members

      Valley Health Plan Member Services
      1.888.421.8444 (toll-free), choose Option 3​

      Choosing and Changing your Primary Care Provider (PCP)

      Valley Health Plan (VHP) offers you several ways to choose a Primary Care Provider (PCP). We encourage you to take the time to research available Primary Care Provider and make an informed choice based upon you and your family’s needs and preferences.

      Ways to make an informed decision:

      • Visit the VHP Provider Search to learn more about VHP’s network of doctors and which doctors are available to you within your plan.
      • Contact Member Services at 1.888.421-8444 (toll-free) to speak with one of our knowledgeable and friendly Member Service Specialists.
      • Use the internet to research physicians that you find in the VHP Provider Search to read about their credentials, affiliations, and specialties. You can also use the internet to find out what other patients say about the care they receive from a physician.
      • Talk to your friends, family, and neighbors. Often the best information comes from the people you know and trust.

      As a Member, you have the right to change your Primary Care Provider (PCP) at any time. The change will take effect on the first day of the next month after your request is received. During that time a new Member ID card will be sent to you with the name of your new PCP.

      It is important that you wait to seek services from you r new PCP until the change has become effective or you could be financially responsible for any services received.

      To choose or change your PCP, contact VHP Member Services at [email protected] or by phone at 1.888.421.8444 (toll-free).​

      If you or your Dependent(s) have an Acute Condition, a Serious Chronic Condition, a Pregnancy, a terminal illness, or your newborn child between birth and age 36 months is under medical care, you may be eligible to continue to receive treatment from your provider (e.g. physician or hospital):

      • ​if your treating Plan Provider terminates as a VHP Plan Provider, or

      • if you are receiving care from a non-participating provider at the time of your enrollment in VHP Plan.

      You have the right to request a copy of the Plan’s continuity of care policy. To request a copy of this policy, call Member Services at 1.888.421.8444 (toll-free).

      To choose or change your PCP, contact VHP Member Services at [email protected] or by phone at 1.888.421.8444 (toll-free).​

      For more information visit the VHP Continuity of Care page. 

      Everyone is concerned about rising health care costs and many assume there’s nothing they can do about it. However, estimates are that up to 3 percent of health care costs are wasted by overstated, double-billed, or otherwise fraudulent charges. We all pay for these excesses. Valley Health Plan (VHP) is committed to the prevention, detection and reporting of health care fraud, waste and abuse. You, our health plan members, are a vital part of helping us address this problem. In the process, you are protecting yourself from unnecessary higher costs and potentially more serious concerns, such as identity theft.

      We encourage members to notify VHP of any suspicious activity you might encounter while receiving care from one of our practitioners or providers. All complaints regarding fraud will be investigated. This will allow VHP to take the necessary actions to protect members from unlawful activities.

      For more information about how to spot and report suspicious activity visit the Fraud, Waste, and Abuse page. 

       

      Your benefit plan requires members to obtain all covered services through Plan Providers in the VHP Network, except in the case of an Emergency Room or out-of-area Urgent Care visit. If you seek services from Non-Plan Providers without a VHP approved referral, you may be financially responsible for the charges.

      To find a Plan Provider – use our Provider Search or contact VHP Member Services for assistance at:

      1.888.421.8444 (toll-free)​
      Monday - Friday
      9:00am-5:00pm

       

      We understand that health coverage can be intimidating. Sometimes you read about your benefits and it seems like they are written in a foreign language. The VHP Glossary of Health Coverage and Medical Terms can help you understand common health coverage terms, so you can get the most out of your plan.

      Download a PDF copy of the VHP Glossary of Health Coverage and Medical Terms

       

      As a Member, you are entitled to certain rights and services. You also have a responsibility to participate in your health care. A good partnership between you and your PCP will enhance our ability to provide appropriate services and for you to get the most from your coverage plan. 

      Visit the VHP Member Rights and Responsibilities page for a complete list of your rights and responsibilities.

       

      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 you, the Member. Except in the case of Emergency Services, Urgently Needed Services, or if VHP has Prior Authorized services, you must receive all of your care from these VHP Plan Providers. If you receive services outside of the VHP Network without Prior Authorization, you may be responsible for the charges

      VHP's Referrals/Prior Authorizations

      The Utilization Management (UM) Department ensures appropriate use of resources by evaluating and determining coverage for medical care services for members and providers.

      To receive information about the UM process or the status of authorizations and referrals, call Member Services at 1.888.421.8444 (toll-free), Monday through Friday, 9:00 a.m. – 5:00 p.m. PST.  

      Language services are available at any time, for the hearing and speech impaired, call the California Relay Service (CSR) by simply dialing 711 or the 800 CRS number of your modality. All calls received after business hours, on weekends, and on holidays will be returned on the next business day.

      The California Department of Managed Health Care (DMHC) requires health plan members to be seen in a timely manner. The primary intent of these regulations and the underlying legislation is to ensure that the VHP network of providers has the capacity and availability to provide care to you within certain timeframes for the various levels of care. However, sometimes waiting longer for care is not a problem. Your physician may give you a longer wait time if it would not be harmful or your health. It must be noted in your record that a longer wait time will not be harmful to your health.

      Please take time to read the following California Timely Access Standards on the VHP Timely Access page. 

      Employer Group Plan Information

      The Employer Group Plan Information section is where you will find information to help you get the most out of your health coverage specific to our Classic and Preferred Employer Group Plan Members.

      Large Hispanic family having dinner outside

        Valley Health Plan's Employer Group Plan provides an explanation of your rights, benefits, services, and responsibilities as a Classic or Preferred Employer Group Plan Member. It also explains Valley Health Plan's health maintenance organization responsibilities to you. 

        Employer Group Combined Evidence of Coverage (EOC)

         

        The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit us at www.valleyhealthplan.org or call 1-888-421-8444. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call  1-888- 421-8444.

        Summary of Benefits and Coverage (SBC) for Classic and Preferred Plans

        The Schedule of Benefits and Coverage Matrix (SOBM) can be used to help you compare coverage benefits and is a summary only. The Evidence of Coverage (EOC) and Plan contract should be consulted for a detailed description of coverage benefits and limitations. 

        Schedule of Benefits and Coverage Matrix (SOBM)

        Members of VHP's Classic or Preferred Plan can fill out a VHP temporary ID card if you are in need of services or a prescription and have either lost or not yet received your permanent VHP ID Card. If you are a member of the PMGSJ Network or SCCIPA Network, please be sure to use your Network-specific ID Card.  All other Classic or Preferred Plan Members should use the VHP Employer Group Temporary ID Card

        VHP Employer Group Temporary ID Card

        VHP Employer Group PMGSJ Network ID Car

        VHP Employer Group SCCIPA Network ID Card

        Covered California and IFP Information

        The Covered California and Individual & Family Plan Information (IFP) section is where you will find information to help you get the most out of your health coverage specific to our Covered California and IFP Members.

        Group of women and young boy exercising in a park

          Valley Health Plan's Covered California and IFP Plan Combined Evidence of Coverage (EOC) provides an explanation of your rights, benefits, services, and responsibilities as a Covered California or IFP Plan Member. It also explains Valley Health Plan's health maintenance organization responsibilities to you. 

          VHP's Covered California and IFP Combined Evidence of Coverage (EOC)

          The Summary of Benefits and Coverage (SBC) can help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit us at valleyhealthplan.org or call 1-888-421-8444. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call  1-888- 421-8444.

          The Schedule of Benefits and Coverage Matrix (SOBM) may be used to help you compare coverage benefits and is a summary only. The Evidence of Coverage (EOC) and Plan contract should be consulted for a detailed description of coverage benefits and limitations. 

          To view all of the Coveredn California and IFP SBCs and SOBMs visit the page linked here.Covered California and IFP Summaries of Benefits and Coverage (SBC) and Schedules of Benefits and Coverage Matrixes (SOBM)

           

          Members of VHP's Covered California or IFP Plans can fill out a VHP temporary ID card if you are in need of services or a prescription and have either lost or not yet received your permanent VHP ID Card. If you are a member of the PMGSJ Network, please be sure to use your Plan and Network-specific ID Card.  All other Covered California Plan Members should use the VHP Covered California Temporary ID Card and all other IFP Plan Members should use the VHP Individual & Family Plan Temporary ID Card

          VHP Covered California Temporary ID Card

          VHP Covered California PMGSJ Network ID Card

          VHP Individual & Family Plan Temporary ID Card

          VHP Individual & Family Plan PMGSJ Network Temporary ID Card

           

          Additional Resources

          The Additional Resources section is where VHP Members can find helpful information such as immunization schedules and how to request electronic medical records.

          Girl catching baseball at SJ Giants game

             

            Immunizations, also known as vaccinations, help protect you and your children from getting an infectious disease. When you get yourself or your child vaccinated, you help protect others as well

            Immunizations are important for a variety of reasons. By receiving an immunization for a disease, a person defends him or herself against catching that disease. But the benefits do not stop there; society gains a collective immunization as more and more people become immune to a particular disease.

            CDC Immunization Schedule Recommendations or Information

            English Versions

            Link to immunization schedule for infants and children (birth to 6 yrs)

            Link to immunization schedule for children and adolescents (7 yrs to 18 yrs)

            Link to immunization schedule for adults (19 yrs and older)


            Versiones en Español

            Enlace a Vacunas recomendadas para niños, desde el nacimiento hasta los 6 años de edad

            Enlace a Vacunas recomendadas para los niños desde los 7 hasta los 18 años de edad

            Enlace a una Serie de Informacion para Adultos Vacunas

            Valley Health Plan offers Pediatric Dental Services through The Liberty Dental Plan of California Program (LDP). This provides essential pediatric dental care through a convenient network of Contract Dentists in the VHP service area. These Dentists are screened to ensure that our standards of quality, access, and safety are maintained. The network is composed of established dental professionals. When you visit your assigned Contract Dentist, you pay only the applicable Copayment for Benefits up to the Out-of-Pocket Maximum.

            Link to find a Liberty Dental Dentist

             

            You have a right to your health records. A federal law called the Health Insurance Portability and Accountability Act (HIPAA) gives you the right to see and get a copy of your health record. Most health insurance plans and— including doctor’s offices, clinics, hospitals, pharmacies, labs, and nursing homes — must follow this law.

            Lucile Packard Children's Hospital  Electronic Medical Records

            Natividad Medical Records 

            Santa Clara Valley Medical Center (SCVMC) Medical Records 

            Stanford Health Care Medical Records 

            Sutter Health and Palo Alto Medical Foundation (PAMF) Electronic Medical Records 

             

            To make a Third-Party Liability (TPL) Inquire follow the process below:

            • Billing/Lien/Subpoena Records Requests - mail to:  Valley Health Plan 2480 N. First St, Ste 160, San Jose, CA 95131 along with a copy of the HIPAA signed authorization (addressed to Valley Health Plan) and a $15.00 check payable to Valley Health Plan.
            • Inquires:  To follow up on a request, please fax a recent inquiry to 1.408.885.5926 or call 1.408.885-5931.
            • Questions:  Please ​email to [email protected]​.​

             

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