Utilization management

Sharp Health Plan’s utilization management guidelines are designed to help you and your patients.

Use the contact information below to get details about utilization management for Sharp Health Plan commercial members.

For mental health and substance use disorder servicesContact number
Sharp Health Plan1-858-499-8300
For medical servicesContact number
Greater Tri Cities IPA1-877-207-7600
Individually contracted providers1-858-499-8300
Optum Care-North County SD (formerly Primary Care Associates Medical Group)1-760-542-6757
Rady Children's Health Network / CPMG1-858-309-6270
Sharp Community Medical Group – Arch1-858-613-8910
Sharp Community Medical Group Graybill and Temecula1-760-291-6615
Sharp Community Medical Group1-877-518-7264
Sharp Rees-Stealy Medical Group1-858-499-2600

Medical prior authorization

Use our guide to determine when prior authorization is required. Guidelines are specific to services for members enrolled in an HMO plan and assigned to providers who are independently contracted with us.


Pharmacy prior authorization

To prescribe a medication that requires authorization, complete the prior authorization request form and provide any relevant support or documentation.


Behavioral health prior authorization

See what mental health and substance use disorder services require prior authorization for our commercial plan members.


Manuals and guides

Here are some useful manuals and guides to help you better manage your Sharp Health Plan patients.


Commercial provider forms

Browse, download, and print enrollment forms, authorization request, appeal requests, and other useful documents.


Medicare provider forms

You can find Medicare forms and authorizations on the Sharp Direct Advantage website.


Language assistance program

Quality care depends on clear communication between you and your patients. Get the right support so that no questions are left unanswered.


Pre-certification for POS plans

Members with POS plans can choose the providers and level of coverage that work best for them. If they choose an out-of-network provider, their out-of-pocket costs will be higher. Members don’t need a referral from their primary care physician, but some services require pre-certification. Refer members to the health plan benefits and coverage matrix for details on deductibles, copayments, and coinsurance for the POS plans’ HMO Benefit Level and OON Benefit Level.

Have questions?

Our Provider Relations team is here to help.