For application developers

Developing FHIR^® resources to deliver clear, standardized data formats to registered application, or app, developers.

Sharp Health Plan provides resources for third-party app developers, healthcare providers, and insurance providers to access application programming interfaces, known as APIs, as well as documentation and registration services pursuant to the Centers for Medicare & Medicaid Services (CMS) Interoperability and Patient Access Final Rule, CMS-9115-F and CMS Interoperability and Prior Authorization Final Rule, CMS-0057-F.

OptumHealth Behavioral Solutions of California (Optum Behavioral Health) manages mental health services and substance abuse disorder on behalf of Sharp Health Plan. Pursuant to the Centers for Medicare & Medicaid Services (“CMS”) Interoperability and Patient Access Final Rule (CMS-9115-F), Optum Behavioral Health has published a behavioral health Provider Directory API to allow Third Party Applications to retrieve the applicable Optum Behavioral Health provider directory information.

Support

If you have questions or concerns, please contact Sharp Health Plan’s Service Desk at SHP.ServiceDesk@sharp.com.

API documentation

Sharp Health Plan

• Provider Directory API documentation

Retrieve, as applicable, certain provider and pharmacy directory information.

• Patient Access API documentation

Retrieve, as applicable and with the approval of the requesting enrollee or personal representative, certain data concerning adjudicated claims, encounter data from capitated providers and certain clinical data, if Sharp Health Plan maintains any such data.

Patient Access API endpoint

• Formulary API

Retrieve, as applicable, certain formulary information.

• Provider Access API

Providers may retrieve a patient’s clinical data when there is an active treatment relationship which is determined by primary care provider assignment, claims, referrals, or authorizations with assignment or service dates within the last 18 months.

Providers who use Epic and wish to connect can start by contacting Sharp Health Plan’s Service Desk at the email above. Providers who do not use Epic must start by registering a client record with Epic. Then contact Sharp Health Plan’s Service Desk to share the test and production client IDs provided by Epic during the registration process.

• Prior Authorization API

Three prior authorization APIs streamline the referral process for providers. Coverage Requirement Discovery (CRD) will determine whether a service is covered, prior authorization is required, or a service is delegated. Documentation Templates and Rules (DTR) allows providers to submit supporting documentation electronically. Prior Authorization Support (PAS) facilitates authorization submission and status updates.

Providers who wish to connect can start by following the process described for the Provider Access API, above.

• Payer-to-Payer API

Members may opt into sharing clinical, claims, and authorization data between Sharp Health Plan and another payer when transferring to or from Sharp Health Plan or coordinating benefits between concurrent payers.

Payers who use Epic and wish to connect can start by contacting Sharp Health Plan’s Service Desk at the email above. Payers who do not use Epic must start by registering a client record with Epic. Then contact Sharp Health Plan’s Service Desk to share the test and production client IDs provided by Epic during the registration process.

Optum Behavioral Health

• Optum Behavioral Health Interoperability APIs

Retrieve, as applicable, certain Optum Behavioral Health provider directory information.

Machine-readable files

Sharp Health Plan files

Pursuant to CMS regulations under the Transparency in Coverage rule, developers may access Sharp Health Plan’s machine-readable files using the links below.

These files are in JSON format and are updated monthly as required by CMS. Visit our frequently asked questions for more information about Transparency in Coverage.

• Table of Contents
• Allowed Amounts
• In-Network - CAP
• In-Network - FFS

Optum Behavioral Health files

Optum manages mental health and substance use disorder services on behalf of Sharp Health Plan. Pursuant to CMS regulations under the Transparency in Coverage rule, developers may access Optum’s machine readable files using the link below.

These files are in ZIP format, and expanded as JSON format, and are updated monthly.

• Optum Behavioral Health MRFs

Aetna POS files

Meritain Health helps manage benefits, claims, and customer service for Aetna POS plans offered by Sharp Health Plan. Pursuant to CMS regulations under the Transparency and Coverage rule, access is granted to Aetna’s ASA machine-readable files using the link below. To download the required files, you will need to search on the code "ASA_12". These files will be updated monthly.

• Aetna MRFs

First Health PPO files

First Health is a national health benefits company that provides PPO network access on behalf of Sharp Health Plan. Pursuant to CMS regulations under the Transparency in Coverage rule, access is granted to First Health’s machine-readable files using the link below. Files post by the 2nd Tuesday of the month.

• First Health MRFs