Members

The Authorization to Release PHI (PDF, 1.4 MB) (PHI) form authorizes the use or disclosure of your PHI and is voluntary.

Some services require approval or prior authorization before you can receive them. Prior authorization requirements for certain services help to assure that you are getting the services you need when you need them.

Your primary care physician (PCP) or specialist may need to request a referral for additional services that require prior authorization. In these cases they will submit a prior authorization request to Scripps Health Plan. You should always work with your treatment team to make sure that when authorization is required, the provider has received that authorization prior to rendering services.

You will be notified in writing of the determination status of all authorization requests. An authorization approval letter will include the name of the provider and the effective date(s) for the authorization. A denial letter will include the reason for the denial and your rights to appeal the decision. If you do not receive an approval or denial letter, please contact your PCP, specialist or Scripps Health Plan customer service to confirm the approval is in place prior to receiving services.

Typically, your physician will contact Scripps Health Plan to obtain prior authorization, but you are ultimately responsible for ensuring that the prior authorization process is followed.

Scripps Health Plan Services maintains a list of services that require prior authorization. Our network of contracted providers has a list of services that require prior authorization. Members and providers may also contact Scripps Health Plan’s utilization management department for questions or additional information regarding medical necessity criteria.

Prior authorization is NOT required for:

• Emergency services
• Family planning services
• Preventive care, like immunizations and annual physicals
• Basic prenatal care
• Sexually transmitted disease (STD) testing and treatment
• Human immunodeficiency virus (HIV) testing

What is the turnaround time once a prior authorization has been submitted?

Commercial:

• Routine: Within 5 business days
• Expedited: Within 72 hours
• Extension: Within 45 calendar days when it is in the member’s best interest to obtain additional information that would support the request (a member or provider may request this so they can provide the needed information)
• Pharmacy: Routine within 72 hours and Expedited within 24 hours  

Senior:

• Standard: Within 14 calendar days
• Expedited: Within 72 hours
• Extension: Within 14 additional calendar days when it is in the member’s best interest to obtain additional information that would support the request (a member or provider may request this so they can provide the needed information)
• Pharmacy: Standard 72 hours and Expedited 24 hours  

Scripps Health Plan Services maintains a list of services that require prior authorization. Our network of contracted providers has a list of services that require prior authorization. Members and providers may also contact Scripps Health Plan’s utilization management department for questions or additional information regarding medical necessity criteria.

In making referral and authorization decisions, SHPS utilizes clinical guidelines and criteria provided by Centers for Medicare and Medicaid Services (CMS) Criteria using both National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), your health plan criteria, Hayes and MCG (nationally recognized guidelines which are reviewed and updated at least annually).

The Health Care Service Plans (HCSPs) will develop the clinical guidelines based on professionally recognized standards of practice and review all criteria annually.

Learn more in the Prior Authorization Guide (PDF, 210 KB) (effective 1-1-2018).