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.
Please return the completed form to Attn: Member Services, Valley Health Plan, 2480 N. First Street Suite 160, San Jose, CA 95131, or fax it to (408) 885-4425.
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.
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.
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.
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
We encourage our Members to contact VHP's Member Services at (888) 421-8444 (toll-free) to resolve any of your concerns. However, members wishing to file a Grievance about any aspect of the services provided by Valley Health Plan (VHP) may do so by following the Grievance and Appeals process.
You can download the form below:
- English version member grievance and appeal form.
- Enlace al formulario de quejas
- Liên kết đến biểu mẫu khiếu nại
- 申诉表连接
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
Valley Health Plan’s Risk Management policy can be found below. This policy is used throughout our organization. The policy covers monitoring and assessing all risks including financial, regulatory, and medical risks.
Link to the Risk Management Policy
A prescriber must fill out a Standard California Prescription Drug Prior Authorization or Step Therapy Request 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 (888) 421-8444 (toll-free).
Link to VHP's Prescription Drug Prior Authorization Request or Step Therapy Exception Request Form
Providers can make recommendations for additions to or removal of pharmaceuticals from the formulary to the P&T Coordinator by completing the VHP Formulary Drug Review Request Form. Providers can submit this request form to at Pharmacy Services via email at [email protected] or by fax at (408) 943-8235. For questions regarding the formulary, please contact Pharmacy Services at (408) 793-6765.
Link to VHP's Formulary Drug Review 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 Dispute Resolution, P.O. Box 28387, San Jose, CA 95159. If you have any questions, please call Provider Relations (408) 885-2221 Option 2.
Participating Providers can utilize VHP Access Provider Portal to submit claim disputes through the portal via the following instructions - Quick Start Guide - Claim Disputes
Link to VHP's Provider Dispute Form
Link to fillable version of VHP's Provider Dispute 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
Processes
The Provider Processes section informs VHP Contracted Providers on how to work with VHP in giving care to our members.
Valley Health Plan affirms that:
- Utilization Management decision-making is based only on appropriateness of care and service and the existence of coverage.
- The organization does not specifically reward practitioners or other individuals for issuing denials of coverage.
- There are no financial incentives for Utilization Management decision-makers.
Link below
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
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 (408) 885-5926 or call (408) 885-5931.
- Questions: Please email to [email protected].
Resources
This section contains resources, manuals, and guides our Provider partners might find helpful when working with VHP.
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)
HIPAA is a federal law that requires VHP and its providers to protect the security and privacy of its members' protected health information (PHI). HIPAA provides VHP members with certain privacy rights, including the right to file a privacy complaint. PHI is defined as any individually identifiable health information, including demographic information. PHI includes a member's name, address, phone number, medical information, social security number, date of birth, email address, driver's license number, financial information, etc.
VHP supports its providers' efforts to comply with HIPAA requirements. Because patient information is critical to carrying out health care operations and payment functions, VHP and its providers must work together to comply with HIPAA requirements in terms of protecting patient privacy rights, safeguarding PHI and providing patients with access to their own PHI upon request.
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.
Language and Translation Services: VHP offers language assistance 24/7 to members and providers, free of charge.
Effective July 1, 2023, California Law includes a mandate that a licensed health care practitioner who provides prenatal or postnatal care for a patient must ensure that the patient is offered a screening or is appropriately screened for any type of mental health conditions that may be occurring.
Maternal Mental health: Screening Requirements and Case Management Supports
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) 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
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
The VHP Quality & Strategic Improvement mission is to support the well-being of our members through a commitment to accessible, high-quality, equitable health services and community-focused, local care. Our focus is to improve every aspect of quality within the Valley Health Plan delivery system. Our team monitors and evaluates the activities in hospitals, primary care offices, and anywhere our members receive care. In addition, we also improve, create, and provide quality services and systems internally at Valley Health Plan.
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 (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 (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.
Audit tools
This section contains tools that help prepare Providers interested in contracting with VHP for their site and records reviews.
Link to an example of the VHP Behavioral Health Office Audit Tool
Link to fillable an example of the VHP Medical Clinic Office Audit Tool
Link to an example of the VHP Medical Record Audit Tool