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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.

VIEW/DOWNLOAD MEDICAL PRIOR AUTHORIZATION GUIDE

 

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 service is listed as a “Direct Referral” in the Prior Authorization Guide, approved by the member’s primary care physician, and delivered by a contracted provider, you aren’t required to notify Sharp Health Plan, get authorization, or submit referral forms.

Referral & prior auth request form

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

DOWNLOAD THE FORM ➜

Notification only

If a service requires “Notification,” you must fax a Prior Authorization Request Form to 1-619-740-8111 at least 3-7 business days before the scheduled procedure, or within 1 business day if the member is admitted unexpectedly.

 

Pharmacy prior authorization

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

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