*Please refer to the “Plan Specific Addendums” in the provider manual for prior approval
requirements for each health plan.
The following information is provided to you and your staff to aid in the process
of filling out an Initial Care Plan (ICP) to initiate the pre service
approval process for
treatment. The ICP is a two-page document that should be filled out and faxed to
TRIAD the same day that the patient has been seen. Please fax care plans to: 866-225-1033
- ICPs should be submitted before the second visit or, within fourteen business
days
of patient's initial date of entry, whichever occurs first.
-
The initial care plan should include the services provided during the initial visit.
- ICPs should be submitted for patients returning to care with a new diagnosis or patients
returning to care after an interruption of greater than ninety days.
The top portion of both pages must be completed with the name of the primary treating
physician providing care to this patient. Indicate your office and fax numbers with
area code. This is important, since all determinations for treatment will be sent
to you at this fax number. Each page must have the patient's name and Member ID
number indicated. Please indicate the date on which the form is filled out.
The information requested in the initial care plan must be legibly provided on the
form. If any required field on the form is omitted, or otherwise illegible, you
will receive notice that you have failed to follow the proper procedure for filing
a request for prior approval. Such notice shall be provided to you within 24
hours of the receipt of the invalid submission, and shall include a description
of the failure and the proper procedures to follow in order to rectify and re-submit
the request.
You may elect to submit additional information (i.e. medical records, SOAP notes) to Triad Healthcare
Inc. for review in addition to the prior approval form (care plan). Additional documentation is not required but will be accepted and
reviewed by a Triad clinician. Additional information can be attached to the care
plan, or faxed separately to 866-225-1033.
If you do not receive a response from TRIAD within twenty-four (24) hours of your
submission, please call TRIAD at 800-409-9081. Please type or print
legibly in black ink throughout the forms.
View manual online in pdf (Adobe Acrobat)
format or download the complete manual.
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