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.