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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 process​ 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.

The following table identifies what Covered Services will require a Prior Authorization in order for services to be covered by VHP.

BENEFIT
AUTHORIZATION REQUIRED
Acupuncture​​
Yes
Ambulance Services-Non Emergent​
Yes
Bariatric Surgery
Yes
Behavioral Health Outpatient (Non-Psychiatrist)
No
Behavioral Health Outpatient (Psychiatrist)
Yes
Chemo/Radiation/Infusion Therapy
Yes
Chiropractic Care
Yes
Clinical Trials
Yes
Custom-Fabricated Oral Devices or Appliances
Yes
Dermatology
Yes
Diabetes Care Management
No
Diabetes Education
No
Dialysis-Facility
Yes
Dialysis-Physician
Yes
Durable Medical Equipment
Yes
Elective Abortion Services-Facility
No
Elective Abortion Services-Physician
No
Emergency Medical Transportation
No
Emergency Services-Facility (ER)
No
Emergency Services-Physician
No
Eye Contact Lens-Aniridia and Aphakia
Yes
Eye Exam 19 Over-Medical Only at PCP Office
No
Eye Hardware 19 Over-Aniridia and Aphakia
Yes
Genetic Lab Tests
Yes
Hearing Aids-Device
Yes
Hearing Aids-Exam
No
Home Health Care Services
Yes
Hospice Inpatient Respite
No
Hospice Inpatient Respite (Non-Contracted)
Yes
Hospice Services
No
Hospice Services (Non-Contracted)
Yes
Hospital Stay Facility
Yes
Hospital Stay Physician/Surgeon Fee (Inpatient)
Yes
Imaging (CT/Pet Scans, MRI)
Yes
Infertility Treatment
Yes
Inherited Metabolic Disorder-PKU Testing
No
Injections Non-Immunizations
Yes
Intravenous Infusion Outpatient (IV Infusion)
Yes
Lab (non contracted)
Yes
Lab Tests
No
Ob/Gyn
No
Ob/Gyn (Non-Contracted)
Yes
Outpatient Facility
Yes
Outpatient Physician/Surgical Services
Yes
Prenatal Care-Preconception Ob/Gyn Visit
No
Preventive Care/Screening/Immunization
No
Primary Care Visit
No
Rehabilitation Habilitation Services
Yes
Skilled Nursing Facility
Yes
Specialist Office Visit
Yes
Substance Abuse Outpatient (Non-Psychiatrist)
No
Substance Abuse Outpatient (Psychiatrist)
Yes
TMJ Services
Yes
TMJ Services-Appliance Only (Reimbursement)
No
Urgent Care
No
Urgent Care(non contracted)
Yes
X-Rays and Diagnostic Imaging, Non-Routine (CT, MRI, MRA, PET Scan, DEXA, Nuclear Medicine, Radiation Therapy, Other) (Contracted and Non-Contracted)
Yes
X-Rays and Diagnostic Imaging, Routine (Ultrasound and X-ray) (Contracted) if services provided pursuant to an authorized specialty office visit
No
X-Rays and Diagnostic Imaging, Routine (Ultrasound and X-ray) (Non-Contracted) if services not provided pursuant to an authorized specialty office visit
Yes
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Last updated: 3/29/2019 9:47 AM