Obtaining Required Authorization
Except for primary care physician (PCP) services, emergency services, and obstetric and gynecologic services, you are responsible for obtaining valid authorization before you receive covered benefits.
To obtain a valid authorization:
| • | Prior to receiving care, contact your PCP. |
| • |
Request prior authorization for those covered benefits. In most cases, authorization requests for medical services will be reviewed by your Plan Medical Group. Authorization requests for outpatient prescription drugs are reviewed by Sharp Health Plan. |
| • |
If authorization is approved, you will be notified of the approved provider and the expiration date for the authorization. |
| • |
If authorization is denied, you will be informed of the reason for denial and your appeal rights. |
How Sharp Health Plan makes decisions about your care
Sharp Health Plan uses evidence-based guidelines for authorization, modification or denial of health care services. Plan-specific guidelines are developed and reviewed on an ongoing basis by Sharp Health Plan’s Medical Director, the Utilization Management Committee, and appropriate physicians who assist in identifying community standards of care. A copy of the guidelines used in the authorization process is available upon request.
At Sharp Health Plan, we make utilization management decisions based only on appropriateness of care and service (after confirming health coverage). The doctors and nurses who conduct utilization reviews are not rewarded for denials of care or service, and there are no incentives for utilization management decision-makers that encourage decisions resulting in underutilization of health care services.
We’re here for you
| • | Sharp Health Plan staff are available 8 am to 5 pm, Monday through Friday to answer questions from providers and members regarding utilization management issues. |
| • | After business hours and on weekends, callers can speak with a nurse at Sharp Nurse Connection® by calling 1-800-359-2002 or (619) 228-2300 and following the prompts. Callers also have the option of leaving a voicemail message for return call by the next business day. Staff are identified by name, title and organization name when making calls about utilization management issues. |
| • | A toll-free number (1-800-359-2002) is available 24 hours a day, 7 days a week to accept collect calls regarding utilization management issues. |
| • | Sharp Health Plan assists members who are deaf, hard of hearing or speech impaired. TDD/ TTY services are available to all members by dialing “711” or dialing directly through the California Relay Service’s toll-free telephone numbers as follows: |
| 1-800-735-2922 Voice | |
| 1-800-855-3000 Spanish Voz y TTY (teléfono de texto) | |
| • | Language assistance is also available for members to discuss utilization management issues. Call Customer Care at 1-800-359-2002 or (619) 228-2300 to be connected. |
If you have any questions, please don’t hesitate to pick up the phone and call Customer Care at (619) 228-2300, toll-free at 1-800-359-2002 or send an e-mail via our Contact Us form.
