Fax authorizations

For Fax Authorizations, complete and submit the Authorization Request Form (below). Clearly identify the service requested and the medical justification for this service. The following information is required on the request:

• Diagnosis (ICD-10)
• Service Requested (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” 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.

Authorization Request Form

Prior authorization guidelines

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.

Prior Authorization Guidelines

Post stabilization telephone number

Valley Health Plan requires prior authorization for all post stabilization care.  Effective immediately please be advised that the number to call 24hrs per day/7 days per week is 1-855-254-8264.

Any call to any phone number other than 1-855-254-8264 does not constitute notice of patient admission or request for post stabilization care.

A fax about a patient admission or request for transfer does not constitute notice of this request either.  This request must come via phone call to 1-855-254-8264.