Referrals / Prior Authorizations
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.
All VHP Covered Services are provided, arranged for, and/or coordinated by your PCP. To receive Covered Services that requires a referral or Prior Authorization:
- your VHP PCP must initiate the referral or Prior Authorization including services to a specialist;
- as needed, this request is submitted to VHP for approval or denial; and
- VHP must also provide the authorization to you, the Member, before you can receive the services.
You and your PCP will receive written notification whether a referral or Prior Authorization request was approved or denied. VHP has five (5) business days to process a routine request and 72 hours for urgent requests.
If you believe that your PCP, VHP Plan Providers or VHP have improperly denied a request for treatment or services, you have the right to file a Grievance by calling VHP Member Services at 1.888.421.8444 (toll-free). You should file this Grievance within 180 days of the initial denial. If the service you requested is still denied; you may file an appeal with Member Services.
Prior Authorization Guidelines