Understanding prior authorization

Certain services need approval first.

Prior authorization: Your green light to access care

Prior authorization, also known as preauthorization, means getting the green light from Sharp Health Plan before you receive certain medical services, treatments, or medications. It ensures the care you’re seeking is covered under your benefit plan. Prior authorization helps you avoid unexpected medical bills by confirming that:

The service is medically necessary.
It’s the right care for your condition.
It’s covered under your benefit plan.

Precertification: Your seal of approval

Precertification is closely related to prior authorizations. Precertification is the process by which Sharp Health Plan reviews a request for medical services to determine whether it meets certain criteria for coverage. Precertification often applies to:

Complex imaging services like MRIs and CT scans.
Certain surgical procedures.
Certain prescription drugs.

Why both matter

Both prior authorization and precertification are designed to ensure that the care you receive is appropriate, necessary, and covered. They protect you from incurring costs for treatments that may not be covered under your benefit plan or are not medically necessary. They also encourage communication between Sharp Health Plan and your health care providers, leading to better coordinated care.

Getting started

Depending on what benefit plan you’re enrolled in, and what services you’re seeking, you may need to complete a prior authorization or precertification request.

TIP: Prior authorization and precertification are not required for primary care physician services, outpatient behavioral health services, OBGYN services in your network or emergency care services.

Prior authorization

For members enrolled in benefits through one of our Health Maintenance Organization (HMO) plans.

You are responsible for obtaining valid authorization before you receive certain care. To obtain a valid authorization:

Contact your primary care physician (PCP)

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

TIP: Check your Member Handbook (also called your EOC) for a list of services that require 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.

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.

You will receive a confirmation letter

Routine requests are processed within 5 business days, and urgent requests are processed within 72 hours. For approved requests, you will receive a letter in the mail. For denied requests, you’ll receive a letter with the reason for denial and your appeal rights.

TIP: Approved authorizations include an expiration date, so be sure to make a note of it with any other important health information you track.

Precertification

For members enrolled in benefits through our point of service (POS) or preferred provider organization (PPO) plan.

POS Members:

Some Tier 2 (Aetna Open Choice) and Tier 3 (out-of-network) services require precertification before you receive services. It is your responsibility to make sure that you receive precertification.

PPO Members:

Some Tier 1, Tier 2 and Tier 3 services require precertification before you receive care. It is your responsibility to make sure that you receive precertification.

Services that require precertification:

Log in to your Sharp Health Plan online account to read your benefit matrix and find out which services require precertification.

Requesting precertification:

To request precertification, have your doctor complete the POS/PPO Precertification 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.

Questions: We’re here to help

Our team is here to help guide you, so that you can focus on what really matters – your health. If you have questions, please contact our Customer Care team at the phone number listed on the back of your Sharp Health Plan member ID card.

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.