Obtaining prior authorization and precertification

Prior authorization

Except for Primary Care Physician (PCP) services, emergency services and obstetric and gynecologic services, you are responsible for obtaining valid authorization before you receive covered HMO benefits.

To obtain a valid authorization:

• Prior to receiving care, contact your PCP.
• Request prior authorization for those covered benefits. In most cases, authorization requests for medical services will be reviewed by your Plan Medical Group. Authorization requests for outpatient prescription drugs are reviewed by Sharp Health Plan.
• If authorization is approved, you will be notified of the approved provider and the expiration date for the authorization.
• If authorization is denied, you will be informed of the reason for denial and your appeal rights.

Precertification

If you have a Point of Service (POS) plan, some Tier 2 - Aetna/ or Out-of-Network services require precertification before you receive services. It is your responsibility to make sure that you receive precertification. To request precertification, have your doctor complete the POS Precertification Form and fax it to Sharp Health Plan.

If you do not receive required pre-certification, you may be required to pay 50% of the amount Sharp Health Plan pays the provider for that service rather than the coinsurance amount listed on your Benefits Matrix. The 50% payment will not count toward your deductible or annual out-of-pocket maximum. If the service is not found to be medically necessary, you will be required to pay 100% of the charges. You can log onto SharpConnect to read your Benefits Matrix and find out which services require precertification.

How Sharp Health Plan makes decisions about your care

Sharp Health Plan uses evidence-based guidelines for authorization, modification or denial of health care services. Plan-specific guidelines are developed and reviewed on an ongoing basis by Sharp Health Plan’s Medical Director, the Utilization Management Committee, and appropriate physicians who assist in identifying community standards of care. A copy of the guidelines used in the authorization process is available upon request. At Sharp Health Plan, we make Utilization Management decisions based on appropriateness of care and service after confirming health coverage. The doctors and nurses who conduct utilization reviews are not rewarded for denials of care or service, and there are no incentives for Utilization Management decision-makers that encourage decisions resulting in underutilization of health care services.