Medical prior authorization

Learn which services require a referral, notification or prior authorization.


Our prior authorization guide makes it easier to determine when prior authorization is required for a particular service. Note that these guidelines are specific to services for members enrolled in HMO plan and assigned to providers who are independently contracted with Sharp Health Plan. For members assigned to a different plan medical group (PMG), providers should contact the PMG directly for details and their referral and authorization processes. The PMG is identified on the member's identification card.



Utilization management program

Our medical prior authorization guide is part of our utilization management program, which ensures members have access to the high-quality, cost-effective medical services they need, when they need them. Learn more about this program in the provider operations manual.


Direct referrals

If a direct referral is approved by the member’s primary care physician and delivered by a contracted provider, you're not required to notify us, get authorization or submit referral forms.

Referral & prior authorization request form

If a service is listed as “Prior Authorization Required” (unless it’s an emergency), you must fax this form to 1-619-740-8111 and receive approval before scheduling the procedure.


Notification only

If a service requires “Notification,” you must fax a prior authorization request form to 1-619-740-8111 3-7 business days before the procedure, or within 1 business day if the member is admitted unexpectedly.


Pharmacy prior authorization

Looking for pharmacy prior authorization guidance? It’s here.