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Independent providers should fill out this form if a service requires prior authorization. You can fax it to 1-619-740-8111 to receive approval before scheduling a procedure. Providers who are rendering care to members assigned to a plan medical group (PMG) should contact the PMG for prior authorization.
If prior authorization is needed for a specific behavioral health or chemical dependency service, please fill out this form and fax it to 1-619-740-8111 to receive approval.
If a medication requires prior authorization, or step therapy exception, fill out this form and fax it to 1-888-836-0730 (or 1-855-245-2134 for Covered California members).
Members who disagree with a utilization review decision or are dissatisfied with the care they have received, have the right to file a grievance or appeal. Provide members with this form to start the process.
If a member has a point-of-service (POS) plan and requires pre-certification for their services, fill out this form and fax it to 1-619-740-8111 prior to delivering care.
Use this form to request an electronic data interchange (EDI) for claims submission and electronic remittance advice (ERA) in place of paper Evidence of Benefits (EOBs) and checks.
If a member needs to be reimbursed for eligible out-of-pocket medical expenses, they can submit this reimbursement request form within 180 days of the date of service. This form must be submitted directly by the member.
Before we can assist you in the resolution process, we’ll need you to fill out this brief form with your information, patient details, and your description of the dispute.
This form may be used to request dismissal of a Member from your care. Please refer to our policy on Provider-Initiated Member Dismissal in our Provider Operations Manual prior to completing or submitting this form. Once complete, fax to Customer Care at 1-619-740-8571 or send via mail to the address on the form.
Complete this form to refer a member to case management or disease management. Members can also refer themselves by calling 1‑800‑359‑2002.
You can find Medicare forms and authorizations on the Sharp Direct Advantage website.
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