Pre-Certification Guidelines - Initial Care 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 permit pre-certification 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 must 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 must 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 certifications 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 pre-certification. 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.
Additional Information for Pre-service care requests
You may elect to submit additional information (i.e. SOAP notes) to Triad Healthcare Inc. for review. 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 refax or
- Initial Care Plan - (154k)
- w/ Instructions - (161k)