Authorization Process & Forms
Trusted Health Plan™ strives to deliver our local Washington DC providers all the resources they need in order to assist them in providing most efficient and effective treatments. The list of authorization and request forms below is meant to assist you with that process. If there is a form that you feel other providers would find useful to access on this page, please contact us at 202-821-1145.
How Do I get a Service Authorization or Appeal?
All departments can be accessed through the main number at THP (202) 821-1100. Just follow the prompts to reach the Utilization Review (UR) department for authorizations and appeals.
Prior Authorization (PA) requests can be faxed to UR at 202-821-1098. Requests for services will be reviewed by experienced RNs utilizing InterQual criteria and/or other relevant clinical practice guidelines. All denials will be the decision of the THP Medical Director.
- Urgent PA decisions will be made within 3 business days, and oral notification will be made within 48 hours of the decision.
- Non-Urgent PA decisions will be made within 7-14 business days, and oral notification will be made within 48 hours of the decision.
What services require Prior Authorization?
The majority of services offered by THP do not require a Prior Authorization. Wellness care and diagnostic services (such as screenings and labs) require no prior plan notification. Services that do require a Prior Authorization are consistent with other plans. These services include, but are not limited to:
- Inpatient and Outpatient Services
- Rehabilitative Services
- Nursing Home/ Skilled Nursing/Hospice Care
- Major Surgery and General Anesthesia
- Out of Network Providers
- Non Formulary Pharmaceuticals
Emergency Services Notification
Emergency Services and Emergency Transportation do not require a Prior Authorization, but Plan Notification is encouraged as soon as possible.
It is important to complete all relevant information on the Prior Authorization Form. Prior to sending your requests, please be sure that elegibility is checked. Requests will not be processed if they are missing the member number, clinical information, CPT, ICD-9 codes and/or Physician Signatures.
Pregnancy care does not require a Pre-Authorization. However, plan notification of OB services is required. OB care and services will be coordinated by a Trusted OB Case Manager. You may fax this OB Authorization form to UM at 202-821-1098.