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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:
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.
Sharp Direct Advantage is offered by Sharp Health Plan. Sharp Health Plan is an HMO with a Medicare contract. Enrollment with Sharp Health Plan depends on contract renewal. Read the full disclaimer.