Utilization Management
Sharp Health Plan’s utilization management guidelines are designed to help you and your patients. The Prior Authorization Guide for members assigned to Independent PCPs is provided below. Also available is a guide for ACES, Sharp Health Plan's online system for referrals.
| • | Prior Authorization Guide (Independent/ Commercial ONLY — revised April 2012) |
| • | Authorization Claims Enrollment System (ACES) User Guide |
| • | Case Management/ Disease Management Referral Facsimile Transmittal — Complete this form to refer a member. Members may also self refer by calling (619) 228-2300 or 1-800-359-2002. |
For members assigned to the following Plan Medical Groups (PMG), please contact the PMG directly for information regarding referrals and authorizations.
| • | Children’s Physicians Medical Group, (858) 309-6270 |
| • | Greater Tri-City IPA, (760) 941-7309 or toll-free 1-877-207-7600 |
| • | Primary Care Associates Medical Group, (760) 542-6757 |
| • | Sharp Community Medical Group, (858) 499-2550 or toll-free 1-877-518-7264 |
| • | Sharp Rees-Stealy Medical Group, (858) 499-2600 |
In addition, Sharp Health Plan medical policies are available upon request. Please call our Network Development / Provider Support Department at (619) 228-2396, or send an e-mail via our Contact Us Form, and identify the specific medical policy you wish to review.
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 (619) 228-2300 or toll-free at 1-800-359-2002 to be connected. |
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) 228-2396, or send an e-mail via our Contact Us Form.
