Provider Operations Manual
Helping providers who serve Sharp Health Plan members
The Provider Operations Manual was created to assist providers who serve Sharp Health Plan members. For your convenience, the manual is divided into sections. Please click the link to the section you would like to view.
• Introduction
• Brief History
• Product Overview
• Global Emergency Services
• First Dental Health Access
• Smart Partnership
• Glossary
• Member Rights and Responsibilities
• PCP Assignment and Selection
• Member Grievances
• Independent Medical Reviews
• Additional Resources for Members
4. Provider Rights and Responsibilities
• Sharp Health Plan’s Responsibilities
• Provider Responsibilities
• Eligibility Verification
• Access to Care
• Telephone Triage
• Member Dismissal
• Practice Updates
• Health Care Fraud and Abuse
• Privacy and Confidentiality
• Advanced Health Care Directives
5. Covered Benefits & Services
• Covered Benefits
• Exclusions and Limitations
• Supplemental Benefits
• Drug Formulary
• Vision Services
• Cultural and Linguistic Services
• Second Medical Opinions
• Case Management Program
• Quality Improvement Program
• Health Plan Employer Data and Information Set (HEDIS®)
• Preventive Health Services
• Credentialing Program
• Claims and Encounter Data
• Coordination of Benefits
• Out of Pocket Maximum
• Balance Billing
• Bills for Prenatal Genetic Testing
• Dispute Resolution
• Sample Claims Acknowledgement Letter
• Sample Remittance Advice Summary
• Glossary of Remittance Advice Terms
• Sample Detailed Capitation Listing
• Glossary of Capitation Listing Terms
• Sharp Health Plan Prior Authorization Guide
If you can’t find what you are looking for, please don’t hesitate to pick up the phone and call our Network Development / Provider Support Department at (619) 228-2330 or send an e-mail via our Contact Us Form. We’re here to help.
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