Keep your care plan in motion

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

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:

Post-stabilization care

Prior authorization is required for post-stabilization services. Neither Scripps Health Plan nor the member can or will be held financially responsible for any unauthorized care provided by a contracting or non-contracting facility. Contracting and non-contracting facilities are required to timely notify Scripps Health Plan once the member is clinically stable for prior authorization to provide post-stabilization care or to arrange for a post-stabilization transfer. Scripps Health Plan has partnered with Evernorth Behavioral Health for inpatient behavioral health benefits. Timely contact Evernorth Behavioral Health directly for any Scripps Health Plan member admitted for an emergent psychiatric condition.

Emergent Medical (Non-Psychiatric) Admissions or Transfers

Scripps Health Centralized Transfer Center


Emergency Psychiatric (Behavioral Health) Admissions or Transfers

Evernorth Behavioral Health


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

2. MCG

3. Scripps Health Plan Clinical Guidelines

4. Hayes Technology

Preventive Health Care:

Scripps Health Plan - Specific Clinical Guidelines:

Other Resources about Standards of Care:

World Professional Association for Transgender Health

Second opinion

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 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.

Attention: Claims

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: