Do you need prior authorization or a referral for your patient’s care? We’re here to help.
Referrals and authorizations
Scripps Health Plan contracted medical groups maintain a list of services that require prior authorization. Providers should inform the member’s primary care physician of the need for further referral, treatment, or consultation to determine which services must have prior authorization and the process by which services are reviewed for authorization.
For specialists and ancillary providers contracted with the Scripps Clinic and Scripps Coastal medical groups, authorization requests may be submitted through the Scripps Care Link online portal or by fax. If you are not yet signed-up for this easy-to-use and secure Internet resource, please contact Scripps Health Plan’s customer service department at 844-337-3700 or via email at email@example.com.
Scripps Health Plan also maintains a list of services that require prior authorization. These prior authorization requirements are in addition to any required by the medical group. Routine requests should be submitted via fax to 858-260-5877. Urgent requests should be submitted via fax to 858-964-3104.
Prior authorization is NOT required for the following:
- Basic prenatal care
- Emergency services
- Family planning services
- Human immunodeficiency virus (HIV) testing
- Preventive care, like immunizations and annual physicals
- Sexually transmitted disease (STD) services
For questions about services requiring prior authorization:
- Contact the member’s medical group for prior authorization guidelines
- Review the Scripps Health Plan Prior Authorization Guide (PDF, 130 KB) or call Scripps Health Plan customer service at 844-337-3700.
Prior authorization is required for post-stabilization services. Neither Scripps Health Plan Services nor the member can or will be held financially responsible for any unauthorized care provided by a facility.
For emergent medical admissions or transfers, call Scripps Centralized Transfer Center at 858-678-6205.
Utilization management review standards
Scripps Health Plan has adopted clinical guidelines that are nationally recognized, peer-reviewed and evidence-based. This criterion is used when making determinations for prior authorization, concurrent review and retrospective review as well as any medical necessity decisions or clinical issues resulting from claim disputes. Guidelines are reviewed and updated at least annually.
Clinical practice guidelines are not a guarantee of coverage. Members should consult their Evidence of Coverage plan document for information regarding covered benefits.
Members and contracted providers may request copies of Utilization Management guidelines or other review criteria used by Scripps Health Plan in the course of Utilization Management activities by calling the Customer Service Department at 844-337-3700.
Scripps Health Plan uses the following nationally developed clinical guidelines and criteria based on professionally recognized standards of practice, reviewed by actively practicing physicians and adopted and approved by the Scripps Health Plan Medical Management Committee in making referral and authorization decisions. Guidelines are listed in order of priority:
1. State and federal law
3. Scripps Health Plan Clinical Guidelines
4. Hayes Technology
Preventive Health Care:
- Well-baby and well-child (up to age 18) physical exams, immunizations and related laboratory services
- Well-adult physical exams, immunizations and related laboratory services
- Routine gynecological exams, immunizations and related laboratory services
- Screenings for: breast cancer, cholesterol, cervical cancer, colorectal cancer, depression, diabetes, hypertension, obesity, prostate cancer, sexually transmitted infections, tobacco and alcohol use/misuse
- Adult Immunization Schedule
- Childhood and Adolescent Immunizations
- National Guideline Clearinghouse
- Autism Spectrum Disorder in Your Children: Screening
Scripps Health Plan - Specific Clinical Guidelines:
- SHPS 1600 Iron Replacement Therapy (PDF, 530 KB)
- SHPS 1601 Colorectal Cancer Screening (PDF, 290 KB)
- SHPS 1602 Treatment of Varicose Veins - Venous Insufficiency (PDF, 310 KB)
Other Resources about Standards of Care:
A second medical opinion by an appropriately qualified healthcare professional is available if a referral is requested by the member or a participating health professional through Scripps Health Plan’s Utilization Management Department. Referral requests will be reviewed and facilitated through the authorization process.
For more information on prior authorization requirements and timeliness standards as well as a variety of related topics, please review the Provider Operations Manual. (PDF, 1 MB)
Prescription prior authorizations
The Scripps Health Plan Prescription Drug Plan is managed by MedImpact.
Prior authorization is required:
- If the drug is not on the formulary preferred drug list
- For specialty and certain injectable medications
- For drug quantities that exceed recommended doses
For inquiries related to your patient’s pharmacy benefit or prior authorization requirements, please call MedImpact customer contact center at 844-282-5343. You can find the Prescription Prior Authorization Form (PDF, 130 KB).
Mental Health Services
Mental health and chemical dependency benefits are administered through the Evernorth Behavioral Health of California, Inc. network of behavioral health providers. A referral from the member’s primary care physician is not required. To locate a participating provider, please visit well.evernorth.com or call 888-736-7009, 24 hours a day, 7 days a week, or TTY: 711 for the hearing and speech impaired.
Evernorth Behavioral Health of California, Inc.
P.O. Box 188022
Chattanooga, TN 37422
Maternal Mental Health law, as described in California SB 1207 and the Health and Safety Code (Section 1367.625) requires that a licensed health care practitioner (provider) who provides prenatal or postpartum care for a patient shall ensure that all mothers are offered screening or is appropriately screened for maternal mental health conditions.
Members with a positive screening can be referred to our Evernorth Behavioral Health Network of providers and/or be referred to our Care Management Program, which is designed to assist with healthcare needs, care coordination, making appointments and connecting members with community resources.
Did you know that anyone can make a referral to our Care Management Program. Referrals can be made via: