Forms and Resources

The Provider Forms and Resources page was designed to make it easier for our Provider partners to find the forms, guidelines, and instructions that might be needed within the course of working with VHP.  If you are unable to find materials that you need, please fill out the Provider Relations Contact Us form or call us at 408.885.2221

Provider Forms

The Provider Forms section offers information and links to forms that VHP Providers might need to use to help work with Valley Health Plan and give our Members the highest-quality care. 

Pregnant woman in doctor's office. You can see doctor's back

     

    Valley Health Plan adheres to the HIPAA rules regarding protected health information (PHI). PHI may not be used or disclosed to anyone except the person to whom it belongs. However, an individual can authorize certain entities to use or disclose PHI for the purposes of care or treatment. 

    Authorization for Use and/or Disclosure of Protected Health Information (PHI)

     

    If your patient chooses to have a person be their representative to communicate with Valley Health Plan (VHP) on their behalf, please have them complete sections 1-3 of the ARF. Their personal representative may file a grievance or appeal on their behalf and may use, receive, disclose their Protected Health Information.

    Authorized Representative for Grievances and Appeals Form (ARF)

     

    Continuity of Care allows you to receive services at in-network coverage levels for specified medical and behavioral conditions for a defined period of time. Continuity of Care occurs when there are changes to your VHP network, and there are clinical reasons preventing the immediate transfer of care to an in-network Provider. 

    Continuity of Care Request Form

     

    The HIV/AIDS Attestation Form is used to ensure that standing referrals are granted only to Providers who have demonstrated expertise in treating AIDS and HIV.

    HIV/AIDS Attestation Form

     

    Valley Health plan is owned by the County of Santa Clara. As a result, there are four documents that must be completed in their entirety to enroll you with the County as a payee to enable VHP to pay your claims.         

    Instructions for Claims and Tax Form Submission​

     

    In Accordance with, California Health and Safety Code Section 1300.67.04 of the Language Assistance Program Regulations, Valley Health Plan (VHP) needs to identify within its Provider Network those Contracted Providers who are themselves bilingual or who employ other bilingual Providers and/or office staff, attesting to their fluency in languages other than English. Such individuals shall have proficiency in health care terminology and concepts relevant to health care delivery systems in the language other than English as well as English, in addition to education and training in interpreter ethics, conduct, and confidentiality.         

    Link to VHP's Language Attestation Form

     

    The Quality Issue Reporting Form is to be used if a patient, authorized representative, or healthcare provider is concerned about the quality of care a person is receiving.

    Link to the Potential Quality Issue Reporting Form

     

    A prescriber must fill out a Standard California Prescription Drug Prior Authorization form for a member to get a drug that is not on the formulary. The form will be reviewed by a pharmacist and/or a physician and approval will be based on established medical criteria and/or medical necessity. A list of formulary drugs and medical criteria are available at www.valleyhealthplan.org or by calling VHP Member Services at 1.888.421.8444 (toll-free).        

    Link to VHP's Prescription Drug Prior Authorization Request Form

     

    If a VHP claim or authorization is denied, a provider may request reconsideration of denied services in writing. It will be acknowledged in writing to the provider within 15 business days and a resolution will be sent to the provider within 45 business days. This form can be mailed to: VHP Provider Relations Dispute Resolution P.O. Box 28387 San Jose, CA 95159. If you have any questions please call Provider Relations 408.885.2221 Option 2. 

    Link to VHP's Provider Dispute Form


    This online form allows Providers to verify the current information represented in the Provider Directory or submit changes electronically.

    Link to Provider Directory Online Verification and Change Form

     

    Valley Express is the online Provider portal for referrals and Authorization Submissions. Valley express allows you to check eligibility, create referrals, create authorizations, search referrals, search authorizations, and submit clinical documentation with referrals and authorizations.

    Link to Valley Express Access Request form

    Please submit a completed roster to [email protected].  If you have any questions regarding this template please contact Provider Data Management [email protected]

    Link to Valley Health Plan Roster Template​​ 

    Provider Processes

    The Provider Processes section offers information about how VHP Contracted Providers can best work with Valley Health Plan in giving care to our Members

    Doctors conferring while looking at a computer

       

      Valley Health Plan affirms That:

      1. Utilization Management decision-making is based only on appropriateness of care and service and the 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.

      Link below

      Affirmative Statement About Financial Incentives

      Providers needing to request an authorization or referral for a patient can access the Valley Express Online Authorization Form, the Authorization Request Form (TAR) and instructions, and our Post Stabilization phone numbers. 

      Link to the VHP Authorization and Referrals Process

       

      Medical Claims Submission - VHP must receive claims and encounter data from contracted providers within ninety (90) days from the date of service. VHP has 45 working days from the date of receipt to reimburse, contest, or deny a claim.

      All paper claims for covered services provided to eligible Members must be submitted on CMS 1500 Form (for all professional services, durable medical equipment (DME) and supplies and Laboratory Services) or on UB 04 Form (for all institutional facility charges inpatient/outpatient). All claim forms and claim-related documents, and disputes, must be signed and dated by the provider or a designee.

      Link to Contracted Providers' Billing Information

      As required by Assembly Bill 1455, the California Department of Managed Health Care has set forth regulations establishing certain claim settlement practices and the process for resolving claims disputes for managed care products regulated by the Department of Managed Health Care. This notice is intended to inform you of your rights, responsibilities, and related procedures as they relate to claim settlement practices and claim disputes. Unless otherwise provided herein, capitalized terms have the same meaning as set forth in Sections 1300.71 and 1300.71.38 of Title 28 of the California Code of Regulations.

      Link to information about VHP's Claims Settlement Practices and Dispute Resolution Mechanism

       

      Healthcare professionals have the right to review information obtained by Valley Health Plan to support their credentialing application and obtain the status of their application throughout the credentialing process. If you would like to review the information obtained by VHP, please call Provider Relations to set up a time to meet.

      Link to information about your Rights as a Healthcare Professional

      In Accordance with, California Health and Safety Code Section 1300.67.04 of the Language Assistance Program Regulations, Valley Health Plan (VHP) needs to identify within its Provider Network those Contracted Providers who are themselves bilingual or who employ other bilingual Providers and/or office staff, attesting to their fluency in languages other than English. Such individuals shall have proficiency in health care terminology and concepts relevant to health care delivery systems in the language other than English as well as English, in addition to education and training in interpreter ethics, conduct, and confidentiality.

      Link to VHP's Langauge Assistance

      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]​.​

      Provider Resources

      The Provider Resources section offers additional resources to our Provider partners like quick access to Valley Health Plan's Evidence of Coverage for our different lines of business, the Provider Manual, Training, and other helpful materials.

      Back of male as he does a telehealth visit with a female doctor

         

        Link to information about the VHP's 2020 HEDIS Report

         

        The Valley Health Plan Care Management Program works with members to improve their health and quality of life. Our program consists of complex case management, care coordination and preventive health education, including chronic disease self management.  The Care Management Program encompasses two programs:  Condition Management and Complex Case Management. VHP has partnered with AxisPoint Health to co-administrate these programs. AxisPoint Health is a leading provider of care management services, offering more than 25 million enrolled patients immediate access to a broad range of health and disease management services. The Care Management Program is delivered by a team of specially trained registered nurses and other professional staff, using state-of-the-art information systems to provide knowledge, support, and monitoring for patients between practitioner visits. ​

        Link to information about the VHP Care Management Program

        The Clinical Guidelines define the role of specific diagnostic and treatment modalities in the diagnosis and management of patients. The statements contain recommendations that are based on evidence from a rigorous systematic review and synthesis of the published medical literature.

        These guidelines are not fixed protocols that must be followed, but are intended for health care professionals and providers to consider. While they identify and describe generally recommended courses of intervention, they are not presented as a substitute for the advice of a physician or other knowledgeable health care professional or provider.

        Link to VHP's Clinical Guidelines

        Postpartum depression is the most common complication of childbearing. The 10-question Edinburgh Postnatal Depression Scale (EPDS) is a valuable and efficient way of identifying patients at risk for perinatal depression. The EPDS is easy to administer and has proven to be an effective screening tool.

        Link to the Edinburgh Postnatal Depression Tool

        We are continuing to grow and expand our network to bring our Members more choices for care! The Benefits and Coverage Handbook provides information about how to access services, member benefits, and health care consumer rights. 

        Link to VHP's Covered California & IFP and Employer Group Evidence of Coverage (EOC)

         

        Health and Wellness

        Prevention care is an important part of health and wellness.  Remember to remind your patients about their annual exams and screenings to reduce their overall health risks.  You and VHP are your patient's partner in health.

        Link to VHP's Health and Wellness page

        The Clinical Guidelines define the role of specific diagnostic and treatment modalities in the diagnosis and management of patients. The statements contain recommendations that are based on evidence from a rigorous systematic review and synthesis of the published medical literature.

        These guidelines are not fixed protocols that must be followed, but are intended for health care professionals and providers to consider. While they identify and describe generally recommended courses of intervention, they are not presented as a substitute for the advice of a physician or other knowledgeable health care professional or provider.

        Link to VHP's Langauge Assistance

        The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD tool for common mental health disorders administered by health care professionals. The PHQ-2 inquires about the frequency of depressed mood, with a score ranging from 0 to 6. The authors identify a cut-off score of 3 as the optimal cut point for screening purposes and stated that a cut point of 2 would enhance sensitivity.

        Link to VHP's Patient Health Questionnaire PHQ-2

        The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as “0” (not at all) to “3” (nearly every day).

        Link to the Patient Health Questionnaire PHQ-9

        Valley Health Plan (VHP) offers our Members access to an extended network of conveniently located pharmacies in and out of Santa Clara County. (Note: VHP does not cover charges for additional convenience services that Plan Pharmacies may offer.) Providers can find information about formularies, pharmacy locations, forms, medication disposal, and mail-order services for their VHP patients.

        Link to VHP's Provider Pharmacy page

        Valley Health Plan (VHP) greatly appreciates the relationship with our Providers. Together we are partners in the health of VHP Members and our shared community. This manual provides information about how to work with VHP and will describe how will we work together. The Provider Manual also contains policies, procedures, regulatory/contractual requirements to support you in providing comprehensive care to our Members and is designed to help your understanding of our programs and processes. We will update our Provider Manual from time to time as our policies and/or regulatory requirements change.​

        Link to VHP's Provider Manuals

        VHP is responsible for the treatment of MediCal patients with Autism treatment disorder. This may include Speech Therapy, Occupational Therapy, and Behavioral Health Treatments such as Applied Behavioral Analysis (ABA).

         VHP contracts exclusively with Santa Clara Family Health Plan (SCFHP) for Managed MediCal members. Managed MediCal members calling to inquire about these services should be directed to SCFHP Member Services at 1-800-260-2055. VHP does NOT provide member services support for SCFHP Plan Members. The members should NOT be referred to County Mental Health or San Andreas Regional Centers.

         Providers calling to obtain referrals for these patients should be referred to the VHP UM Department at
        408-885-4647. All services must be referred by their PCP, as for any other service. Patients may not self-refer. The UM Department will review for coverage criteria, network participation, and coordination of care as they would with any other service.

         Primary Care Providers are responsible for coordinating Autism care the same as for any other diagnosis; referral for evaluation, review of the evaluation and treatment plan, and prescription of treatment services and duration. Per regulations, all treatment must be prescribed by a physician or psychologist. Primary Care Providers that see patients with autism should visit www.scfhp.com to familiarize themselves with the benefit, treatments available, and available resources.

        Valley Health Plan (VHP) has partnered with local and national Provider training organizations to offer trainings in LGBT Health Research and Care, Cultural Competency Care, Childhood Obesity Prevention, and Child Feeding Skills.

        Link to VHP' Provider Training page

        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.

        Provider Audit Tools

        Providers interested in contracting with VHP must have a site review and a records review conducted prior to being credentialed by VHP. These tools will help you and your staff prepare for an audit. 

        Caucasian male chiropractor adjusting back of Caucasian male patient

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