Prior Authorization Guide

Sharp Health Plan’s prior authorization guidelines for Independent members can be found here. For members assigned to other Plan Medical Groups (PMG), please contact the PMG directly for information regarding referrals and authorizations.

The purpose of the Sharp Health Plan Utilization Management Program is to ensure medically necessary services are rendered at the appropriate level of care in a timely and cost-effective manner. Services are divided into three levels of authorization, based on type of procedure, diagnosis and location of service: (1) Direct Referral, (2) Notification Only, and (3) Prior Authorization.  Please see the Provider Operations Manual for additional information regarding Sharp Health Plan’s Utilization Management Program.

Direct referrals (D)

No notification to or authorization by Sharp Health Plan is required when services identified as Direct Referral in the Prior Authorization Guide are approved by the member’s Primary Care Physician and provided by an appropriately contracted Provider.  No referral form is required for direct referrals.

Notification only referrals (N)

Notification to Sharp Health Plan via the Plan’s Prior Authorization Request Form is required for the services listed as Notification in the Prior Authorization Guide. Prior authorization is not required and services may be provided immediately when rendered by an appropriately contracted Provider. Notification of scheduled procedures must be provided 3-7 business days prior to admission or surgery. Notification of unscheduled admissions must be provided within one business day. If any of these services are noted elsewhere in the Guide as requiring prior authorization, the need for a prior authorization supersedes the PCP's ability to directly refer members for that care.

Services requiring prior authorization (P)

The services listed as Prior Auth in the Prior Authorization Guide require prior approval by Sharp Health Plan, unless provided on an emergency basis. These services should not be scheduled until final notification of approval is received from the Plan.

Fax completed Notification and Prior Authorization Requests to Sharp Health Plan at (619) 740-8570.