Getting prior authorization

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.

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, 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.