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Referral and Prior Authorization Requirements

Referral and Prior Authorization requirements helps to ensure that certain procedures and services are medically necessary prior to receiving treatment.

Referral and Prior Authorization Process

PCPs are responsible for providing primary care and coordinating or arranging for a referral to specialists and for other necessary health care services within the same Plan Medical Group (PMG).

Members have access to other providers affiliated with their PCP’s PMG including but not limited to: hospitals, laboratories, imaging centers, specialty care, emergency rooms and urgent care centers. If a member needs to see a specialist, they will need a referral from their PCP for services to be covered. If a member needs services that cannot be provided at the time of an office visit, such as lab work, diagnostic or imaging services, the ordering provider (PCP or specialist) will provide the appropriate referrals to other plan providers within their PMG that best fit their needs. The provider will also work to obtain any necessary authorizations when required. Prior to services being rendered, members should verify with the provider that the appropriate referrals and/or authorizations are in place to ensure services will be covered.

Members are not able to access care from providers who are part of medical groups other than the same group as the elected PCP. For example, if the member’s PCP is part of Scripps Clinic, the member would not be referred to a specialist or for services with any of the other five medical groups.

Members will have direct access to certain preventive services such as annual mammogram screenings, OB/GYN care within their PMG, and other routine services that may not require a referral from their PCP. A member is allowed to self-refer to an OB/GYN who is not the assigned PCP, if the OB/GYN is part of the same Plan Medical Group as the assigned PCP. This can be verified by accessing the online provider directory at www.scrippshealthplan.com or by contacting Customer Service at 1-844-337-3700.

You will be notified in writing of the determination status of the authorization request. An authorization approval letter will include the name of the provider and the effective dates for the authorization. A denial letter will include the reason for the denial and your rights to appeal the decision.

If You Don't Receive a Prior Authorization

If you self-refer or get unauthorized health care services, the services will not be covered and you will be responsible for the full billed charges.

What is the turnaround time once a Prior Authorization has been submitted?

Routine requests and concurrent reviews: 5 business days from the receipt of the information.
Expedited: 72-hours from the receipt of the information (because your provider believes that your condition is life-threatening). If the request is not deemed to be urgent to the Scripps Health Plan clinical reviewers based on the information submitted, we will make a decision in not more than 5 business days.

Scripps Health Plan ensures all medical necessity requests prior to or concurrent with the provision of health care services shall be made in a timely fashion appropriate for the nature of the member’s condition, not to exceed five (5) business days from the receipt of the information reasonably necessary and requested by the utilization review process to make the determination. Emergent requests when the Member’s condition is such that the Member faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other major bodily function, (requiring expedited review) Scripps Health Plan decision to approve, modify, or deny requests prior to, or concurrent with, the provision of health care services shall be made in a timely fashion appropriate for the nature of the Member’s condition, not to exceed 72 hours after the receipt of the information reasonably necessary and requested to make the determination.