Commercial provider forms

Find all the documents you need at the moment you need them with this handy library of forms and resources.

 

Referral and prior authorization request form (Independent)

If a service requires prior authorization, independent providers should fill out this form and 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.

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Behavioral health and chemical dependency prior authorization request guide and form

Use our helpful guide below to determine when prior authorization is needed for a specific behavior health and chemical dependency service.

If your service requires prior authorization, please fill out this form and fax it to 1-619-740-8111 to receive approval.

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Pharmacy prior authorization request

If a medication requires prior authorization, or step therapy exception, fill out this form and fax it to 1-858-357-2534 for review.

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Member grievance / appeal form

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.

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Pre-certification form for point-of-service (POS) plans

If a member has a 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.

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EDI / ERA enrollment form

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.

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Member reimbursement for medical services

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.

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Provider dispute resolution request form

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.

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Member dismissal request form

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.

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Case management and disease management referral 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.

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Medicare forms

For Medicare forms, authorizations and resources you can find more information by going to the Sharp Direct Advantage website.

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