Prior authorization / precertification

Prior authorization

You are responsible for obtaining valid authorization before you receive care (not including primary care physician [PCP] services, behavioral health services and OBGYN services in your network, and emergency care services). Note: Approved authorizations include an expiration date, so be sure to make a note of it with any other important health information you track.

To obtain a valid authorization:

Contact your PCP

Before receiving care through your covered HMO benefits, contact your PCP’s office and ask your doctor to request prior authorization.

Request prior authorization

Your PCP will submit an authorization request on your behalf to your plan medical group or Sharp Health Plan. In most cases, your plan medical group will review requests for medical services. Sharp Health Plan reviews requests for outpatient prescription drugs.

You will receive a confirmation letter in the mail

Routine requests are processed within five business days, and urgent requests are processed within 72 hours. For approved requests, you will receive a letter with the approved provider and expiration date for the authorization. For denied requests, you’ll receive a letter with the reason for denial and your appeal rights.

TIP: Want to check your request status? The easiest way to check the status of an authorization is to call Customer Care at 1-800-359-2002. You can also contact your doctor’s office to request more information.

Precertification

If you have a Point of Service (POS) plan, some Tier 2 (Aetna Open Choice) or Tier 3 (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 Precertification POS Form and fax it to Sharp Health Plan.

If you do not receive required precertification, 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 benefit 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. Log in to your Sharp Health Plan online account to read your benefit matrix and find out which services require precertification.

How we make 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, Utilization Management Committee, and appropriate physicians who assist in identifying community standards of care. You can request a copy of Sharp Health Plan’s medical policy for a particular service or condition by calling Customer Care at 1-800-359-2002.

Utilization management is the evidence-based practice of evaluating medical necessity, appropriateness and efficiency of health care services, procedures and facilities under a health benefit 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.

Obtaining prior authorization

To access certain services, you will need to obtain authorization first.