;

Behavioral Health Authorization Forms

Behavioral Health Authorization FormsTriWest Healthcare Alliance authorization forms are designed to be completed electronically. The data fields on the forms are fillable: Simply click into the shaded box and type in your information. Different forms are required at different phases of treatment.

We have designed the forms to streamline data entry, requesting only that information which is most relevant to clinical management decision-making. Please do not substitute computer-generated reports or other documents for the information requested: Such data will not be accepted in lieu of your clinical formulation.

Step 1: Initial Evaluation Report

PC3 Initial Evaluation Report
Veterans Choice Program Initial Evaluation Report

After you receive your authorization for a new patient appointment and complete your initial evaluation of the Veteran, complete and submit the Initial Evaluation Report within 14 calendar days of your appointment date:

History of Presenting Problem and Treatment Plan: These sections are fillable and will automatically expand as you type. We require a brief narrative summary for these sections totaling no more than the space allowed, approximately 1-1.5 typewritten pages combined.

Referrals to Other Types of Treatment: Please use the Treatment block of the Treatment Plan section to recommend referrals to other types of treatment or levels of care.

Step 2: Secondary Authorization Request (SAR)

PC3 Secondary Authorization Request Form
Veterans Choice Program Secondary Authorization Request Form

Several sessions prior to the expiration of your initial authorization, decide whether additional sessions will be required to complete your treatment plan. Complete and submit the Secondary Authorization Request (SAR) form if additional sessions will be required.

Authorization Request: Enter the start date for the secondary authorization, the planned frequency of sessions and the number of additional sessions you are requesting. Requests for additional treatment sessions should be for a reasonable number of sessions over a defined period of time, e.g., 12 additional weekly sessions over three months, 6 bi-weekly sessions over three months. Please note that for Choice authorizations, the law allows for only 60 days of treatment approval per authorization. A new authorization must be requested for additional continued care.

Step 3: Completion of Episode of Care

PC3 Episode Completion Form
Veterans Choice Program Episode Completion Form

Complete the Completion of Episode of Care form upon termination of your services and submit it within 14 days of your final session.

Step 4: Claims Service Summary

PC3 Claim Service Summary Form
Veterans Choice Program Claim Service Summary Form

Complete and submit the Claims Service Summary prior to submitting your claims for reimbursement. The Dates of Service that you enter on the Claims Service Summary should correspond to those on your claim.

Psychological/Neuropsychological Testing Authorization Requests

PC3 Psychological Testing Request Form
Veterans Choice Program Psychological Testing Request Form

Complete and submit the Psychological Testing Request Form when requesting authorization for psychological and/or neuropsychological assessment. Please be sure to indicate the psychometric instruments to be administered, the time requested for each, and the total number of hours in your authorization request.