Effective July 1, 2024, providers are required to submit Commercial, PEIA, and Mountain Health Trust (WV Medicaid and CHIP) prior authorizations through The Health Plan (THP) provider portal. Fax and phone requests will not be accepted.

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Medical

• Medical Prior Authorization Request Form
  *WV Commercial, WV PEIA, and WV Mountain Health Trust (WV Medicaid and CHIP) prior authorization requests must be submitted through the provider portal. Fax and phone requests are not accepted.

• Molecular Pathology Request Form

 

Behavioral Health

• ​​​​Admissions Review

• Assertive Community Treatment Authorization Form

• Authorization to Disclose Health Information to Primary Care Providers

• Continuity of Care Consultation Sheet

• Prior Authorization for Drug Screening Form 

• Request for ECT/TMS

• Intensive Outpatient/Partial Hospitalization Request Form

• PRSS Authorization Form

• Psychological Testing Prior Authorization Request Form

• SUD Waiver Form

• Treatment Continuation Request Form

• Treatment Continuation Request Form Behavioral Health Unit