We’ve gathered everything you’ll need to interact with Scripps Health Plan. If you can't find something you're looking for, please contact us at 844-337-3700.
- Scripps Care Link Forms (PDF, 380 KB)
- Provider Directory Updates
- Prescription Prior Authorization (PDF, 130 KB)
- Prior Authorization Form (PDF, 93 KB)
- Provider Dispute Resolution Form (PDF, 160 KB)
- Electronic Fund Transfer (PDF, 100 KB)
- How to become a SHPS provider (PDF, 240 KB)
- Provider Operations Manual (PDF, 750 KB)
- Prescription Drug Formulary (PDF, 3.9 MB)
- Preferred Drug List (PDF, 240 KB)
- Prior Authorization Guide (PDF, 260 KB)
Credentialing and recredentialing process for contracted providers
Scripps Health Plan (SHP) protects its members by assuring that the care they receive is of the highest quality. One way in which SHP accomplishes this is by credentialing our providers in accordance with state and federal regulatory requirements and accreditation standards. Your provider responsibility includes full disclosure of all issues and timely submission of all credentialing and re-credentialing information.
As a provider, you have the right to:
- Nondiscrimination during the credentialing process
- Confidentiality of all information submitted during the credentialing process
- Be notified of information obtained during the credentialing process that varies substantially from what is submitted by you
- Review information submitted to support your credentialing application, with the exception of references, recommendations and peer-review protected information
- Be informed of the status of your application upon request, you can email the Credentialing Department at SHPSCRED@scrippshealth.org
- Receive notification of the credentialing decision within 60 days of the SHP’s decision
- Receive notification of your rights as a provider to appeal an adverse decision made by SHP
- Be informed of the above rights.
Credentialing and recredentialing is required for all contracted providers, practitioners and allied health care professionals (for example, physician assistants and nurse practitioners) and health delivery organizations providing services to SHPS members. The Quality Improvement staff, as part of the credentialing and recredentialing process, may perform site visits and medical record reviews. Providers will be contacted in advance if a site visit or audit is needed
Please review your Provider Manual or call your Provider Relations Specialist if you have any questions regarding the above.
Provider’s Right to Notification and Correction of Erroneous Information
SHP will notify you, the Provider, in writing, in the event that SHP receives conflicting information. Areas where variation from information provided may occur include, but are not limited to, actions on a license; malpractice claims history or board certification. SHP is not required to reveal the source of information that was not obtained to meet verification requirements. A notification to you will identify the information in question and the apparent conflict.
You have the right to correct erroneous information within thirty (30) calendar days of receiving notification from SHP by submitting a written response to:
Scripps Health Plan
Attention: Credentialing 4S-300
10790 Rancho Bernardo Road
San Diego, California 92127
You are required explain any discrepancy and include any proof that may be available in order to support your request. Please be advised that any failure to honestly, fully and completely provide information can be used to recommend and adverse credentialing decision, even if you correct your response. If you do not respond within thirty (30) calendar days of notification, your application will be considered withdrawn and processing will be discontinued. Upon receipt of any response from you, SHP may re-verify the primary source information in dispute. If the primary source information has changed, correction will be made immediately to the credentials file. You will be notified in writing of any correction has been made to the credentials file. If the primary source information remains inconsistent, the Credentialing Department will notify you.
How to become a SHPS provider
Download How to Become a SHPS Provider (PDF, 240 KB) to complete and submit the questionnaire and start the credentialing process.
After receiving the practitioner’s completed questionnaire, SHPS will initiate the credentialing process and will complete the primary source verification based on National Committee for Quality Assurance (NCQA) standards and other pertinent information supplied or collected during the application process.
After medical staff office review, credentialing information is presented to the Credentialing Review Panel for review and approval. The Credentialing Review Panel meets quarterly. Providers are notified in writing of the Credentialing Review Panel’s decision. Final credentialing approval is granted by the SHPS Board of Directors, which also meets on a quarterly basis.
Provider dispute resolution
While we hope that our providers will never have a need to report a dispute, Scripps Health Plan does offer a mechanism for submitting dispute information for review.
Examples of provider disputes include:
- Instances where a provider contends that the amount paid for a covered service is less than the contracted rate, including those claims denied for no authorization
- Instances where there is a disagreement between a provider and Scripps Health Plan’s coding and payment policies
For these types of disputes, the Provider Dispute Resolution Form (PDF, 160 KB) should be completed and faxed or mailed using the contact information on the form. Please call Scripps Health Plan customer service for any questions related to the provider dispute process.
This process should not be used related to medical necessity determinations or circumstances where no initial determination was made by Scripps Health Plan. For more guidance, refer to the Provider Operations Manual. (PDF, 750 KB)