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:
- Emergency services
- Family planning services
- Preventive care, like immunizations and annual physicals
- Basic prenatal care
- Sexually transmitted disease (STD) services
- Human immunodeficiency virus (HIV) testing
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, 260 KB) or call Scripps Health Plan customer service at 844-337-3700
Utilization management review standards
Scripps Health Plan has adopted clinical guidelines that are nationally recognized, peer reviewed and evidence based. This criteria 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 for the Scripps Health Plan for treatment practices and preventative care can be found on the National Guideline Clearinghouse.
The schedule for children and adults can be located on the Centers for Disease Control and Prevention (CDC) website. These guidelines are reviewed and updated at least annually.
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, 750 KB)
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).