Utilization management

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

 

Utilization management contact information

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

For behavioral health and chemical dependency 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
Primary Care Associates Medical Group1-760-542-6757
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
 

Manuals and guides

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

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Medical prior authorization guide

Sharp Health Plan's 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 an HMO plan and assigned to providers who are independently contracted with Sharp Health Plan.

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Commercial provider forms

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

DOWNLOAD FORMS ➜

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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Behavioral health prior authorization guide

Here you’ll find our guidelines for behavioral health and chemical dependency.

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

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Behavioral health services

Learn how to help members get access to the services they need for diagnosis and treatment of behavioral health conditions.

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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.

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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.



Download pre-certification form

Have questions? Our Provider Relations team is here to help.