Medical necessity and prior authorization time frames and enrollee responsibilities
Except for PCP services, outpatient mental health or chemical dependency office visits, MinuteClinic services, Emergency Services and obstetric and gynecologic services, you are responsible for obtaining valid Authorization before you receive Covered
To obtain a valid Authorization:
Prior to receiving care, contact your PCP or other approved Plan Provider to discuss your treatment plan.
Request prior Authorization for the Covered Benefits that have been ordered by your doctor. Your PCP or other Plan Provider is responsible for requesting Authorization from Sharp Health Plan or your Plan Medical Group.
If Authorization is approved, obtain the expiration date for the Authorization. You must access care before the expiration date with the Plan Provider identified in the approved Authorization.
A decision will be made on the Authorization request in a timely fashion based on the nature of your medical condition, but no later than five business days. A letter will be sent to you within two business days of the decision.
If waiting five days would seriously jeopardize your life or health or your ability to regain maximum function or, in your doctor's opinion, it would subject you to severe pain that cannot be adequately managed without the care or treatment that is
being requested, you will receive a decision in a timely fashion based on the nature of your medical condition, but no later than 72 hours after receipt of the Authorization request.
If we do not receive enough information to make a decision regarding the Authorization request, we will send you a letter within five days to let you know what additional information is needed. We will give you or your Provider at least 45 days to
provide the additional information. (For urgent Authorization requests, we will notify you and your Provider by phone within 24 hours and give you or your Provider at least 48 hours to provide the additional information).
If you receive Authorization for an ongoing course of treatment, we will not reduce or stop the previously Authorized treatment before providing you with an opportunity to Appeal the decision to reduce or stop the treatment.
The Plan uses evidence based guidelines for Authorization, modification or denial of services as well as Utilization Management, prospective, concurrent and retrospective review. Plan specific guidelines are developed and reviewed on an ongoing basis
by the Plan Medical Director, Utilization Management Committee and appropriate physicians to assist in determination of community standards of care. A description of the medical review process or the guidelines used in the process will be provided
If you change to a new PMG as a result of a PCP change, you will need to ask your new PCP to submit Authorization requests for any specialty care, Durable Medical Equipment or other Covered Benefits you need. The Authorizations from your previous
PMG will no longer be valid. Be sure to contact your new PCP promptly if you need Authorization for a specialist or other Covered Benefits.
If services requiring prior Authorization are obtained without the necessary Authorization, you may be responsible for the entire cost.