PC3 Secondary Authorization Request at a glance
What it is: The PC3 - Secondary Authorization Request is the form of the TriWest Healthcare Alliance Veterans Affairs (VA) Patient-Centered Community Care (PC3) Program.
Who signs: SIGN the Provider Signature line, then enter Credentials and Date.
A filled-in PC3 Secondary Authorization Request example: a provider requests authorization for a veteran with other insurance
How to fill out PC3 Secondary Authorization Request, box by box
Veteran, patient and other insurance
Enter the Veteran's Name, the DoD ID/Benefits # or Sponsor SSN, the Date Completed and the VA Auth Number.
Enter 1. Veteran's Address, then 2. Patient DOB and Age.
Enter City, State and Zip.
Enter 3. Telephone, then mark 4. Veteran's Service Branch: Army, Navy, USAF, USMC, USCG or Other.
In 5. Other Insurance, mark yes or no; if yes, please specify.
Provider
Enter 6. Provider Name and License Type.
Enter 7. Provider Telephone and Fax.
Enter 8. Provider Address, City, State and Zip.
Enter 9. Provider TIN and Provider NPI.
Diagnosis, hospitalization and treatment progress
Enter 10. DSM-V Diagnosis and 11. Co-Occurring Medical Conditions (Relevant to Treatment) as 1, 2 and 3.
In 12, mark yes or no: Has the patient had a psychiatric hospitalization in the last 90 days. In 13. TREATMENT PROGRESS, enter the Progress toward treatment goals since last report.
Treatment plan update
In 14. TREATMENT PLAN UPDATE, provide a brief and succinct narrative to update your treatment plan, with Problems 1, 2 and 3.
List Goals 1, 2 and 3.
Enter Methods and Treatment.
Authorization request
In 15. Authorization Request, enter the Begin Date for this Auth, Frequency (1xweek, 1xmonth) and # of Sessions for each treatment; the form prints 180 days for the End Date.
CPT Code Treatment: 90832 Individual Psychotherapy (30 min), 90834 Individual Psychotherapy (45 min), 90837 Individual Psychotherapy (60 min), 90847 Family Psychotherapy, 90853 Group Medical Psychotherapy, E/M Code Pharmacologic Management, + 90833 Psychotherapy with E/M (30 min), + 90836 Psychotherapy with E/M (45 min), + 90838 Psychotherapy with E/M (60 min) and Other.
Common questions about PC3 Secondary Authorization Request
Who signs it?
SIGN the Provider Signature line, then enter Credentials and Date.
Where do I file it?
Please fax the completed form to 1-866-284-3736 or upload via the Provider Portal.
Sources
[1] TriWest Healthcare Alliance VA Patient-Centered Community Care (PC3) Program, PC3 - Secondary Authorization Request (the Official source link on this page).