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.

---

• Medical Prior Authorization Request Form

• Molecular Pathology Request Form

• Electronic Claim Fax Cover Sheet

• Prior Authorization for SUD Form

• Prior Authorization for Drug Screening Form 

• Pharmacy Pre-Authorization and Notification Form

• Authorization to Disclose Health Information to Primary Care Providers

• Continuity of Care Consultation Sheet

• Request for ECT/TMS

• Treatment Continuation Request Form