Some services require approval or prior authorization before you can receive them. Prior authorization requirements for certain services help to assure that you are getting the services you need when you need them.
Your primary care physician (PCP) or specialist may need to request a referral for additional services that require prior authorization. In these cases they will submit a prior authorization request to Scripps Health Plan. You should always work with your treatment team to make sure that when authorization is required, the provider has received that authorization prior to rendering services.
You will be notified in writing of the determination status of all authorization requests. An authorization approval letter will include the name of the provider and the effective date(s) for the authorization. A denial letter will include the reason for the denial and your rights to appeal the decision. If you do not receive an approval or denial letter, please contact your PCP, specialist or Scripps Health Plan customer service to confirm the approval is in place prior to receiving services.
Typically your physician will contact Scripps Health Plan to obtain prior authorization, but you are ultimately responsible for ensuring that the prior authorization process is followed.
Prior authorization is NOT required for:
- Emergency services
- Family planning services
- Preventive care, like immunizations and annual physicals
- Basic prenatal care
- Sexually transmitted disease (STD) testing and treatment
- Human immunodeficiency virus (HIV) testing
What is the turnaround time once a prior authorization has been submitted?
- Routine & Concurrent: Within 5 business days
- Expedited: Within 72 hours
- Extension: Within 45 calendar days when it is in the member’s best interest to obtain additional information that would support the request (a member or provider may request this so they can provide the needed information)
- Pharmacy: Routine within 72 hours and Expedited within 24 hours
- Expedited Criteria: Due to you or your provider believing that your condition is life-threatening. If the request is not deemed urgent by the Scripps Health Plan clinical reviewers based on the information submitted, we will make a decision in not more than 5 business days.
- Please refer to your new member enrollment guide or your EOC for complete details.
Scripps Health Plan maintains a list of services that require prior authorization. Our network of contracted providers have a list of services that require prior authorization. Members and providers may also contact Scripps Health Plan’s utilization management department for questions or additional information regarding medical necessity criteria.
You and your provider have a right to request the medical criteria that Scripps Health Plan uses to make authorization decisions by contacting customer service at 844-337-3700 (TTY: 888-515-4065 for the hearing and speech impaired).
The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.
Prior authorization requirements are based on your selected medical group (PDF, 22 KB), so please be sure to work with your PCP to review your care plan and determine if prior authorization will be assigned for your medical services.
Scripps Health Plan provides coverage for emergency services and care unless the member did not require emergency services and care and the member reasonably should have known that an emergency did not exist.
What is an emergency?
An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
- Placing the member’s health in serious jeopardy
- Serious impairment to bodily functions
- Serious dysfunction of any bodily organ or part
Active labor means a labor at a time at which either there is inadequate time to effect safe transfer to another hospital prior to delivery or a transfer may pose a threat to the health and safety of the member or the unborn child.
A member is “stabilized” or “stabilization” has occurred when, in the opinion of the treating physician, or other appropriate licensed persons acting within their scope of licensure under the supervision of a treating physician, the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the member’s condition is likely to result from, or occur during, the release or transfer of the patient.
Urgent care services
Unforeseen injuries or illnesses that require medical attention within a short time frame (usually 24 hours) but which are not life threatening are considered urgent care services. When an urgent situation occurs, please do the following:
- Call your PCP for instructions
- If you are calling during non-business hours and reach an answering service, ask the operator to page your physician or the physician on call
- When you receive a return call, explain the situation and follow the physician’s instructions
What to do in case of emergency
Members who reasonably believe they have a medical or mental health condition which requires an emergency response are encouraged to appropriately use the “911” emergency response system where available.
Life threatening circumstances: Obtain care immediately. Contact your PCP no later than 24 hours after the onset of the emergency, or as soon as it is medically possible for the member to provide notice.
Non-life threatening circumstances: Consult your PCP, anytime day or night, regardless of where you are prior to receiving medical care.
Post-stabilization and follow-up care after an emergency: Once your emergency medical condition is stabilized, your treating health care provider may believe that you require additional medically necessary hospital services prior to your being safely discharged. If the hospital is not part of the plan’s contracted network, the hospital will contact your assigned medical group or the plan to obtain timely authorization for these post-stabilization services. If the plan determines that you may be safely transferred to a plan-contracted hospital, and you refuse to consent to the transfer, the hospital must provide you written notice that you will be financially responsible for 100 percent of the cost for services provided to you once your emergency condition is stable. Also, if the hospital is unable to determine your name and contact information of the plan in order to request prior authorization for services once you are stable, it may bill you for such services.
Appealing a medical necessity decision or clinical issue
If you disagree with a decision to deny, modify or terminate a requested service, you (or your provider or authorized representative) may request an appeal within one hundred and eighty (180) days of the denial. If you need an interpreter or language assistance, an interpreter or other special communication tool will be provided to you at no cost. Please refer to the Appeals and Grievance Process section for instructions on how to file an appeal.
Second medical opinions
You have the right to request a second medical opinion if you have questions or concerns about your care or treatment plan:
- If you question the reasonableness or necessity of recommended surgical procedures
- If you question a diagnosis or treatment plan for a condition that threatens loss of life, limb or bodily function or for a serious chronic condition
- If you don’t understand why certain care is being recommended or prescribed to you
- If a diagnosis is unclear due to conflicting test results
- If your treatment plan does not appear to be improving your overall health condition
A second medical opinion will be provided on an expedited basis, where appropriate. If you are requesting a second opinion, the second opinion will be provided by a physician within the same medical group as your PCP. If you are requesting a second opinion about care received from a specialist, the second opinion shall be provided by any plan specialist of the same or equivalent specialty. All second opinion consultations must be pre-authorized. A second opinion will be given to you outside of your medical group if requested to a specialist outside of network, only if the services are not available in-network. Your PCP may also decide to offer such a referral even if you do not request it. State law requires that health plans disclose to members, upon request, the timelines for responding to a request for a second medical opinion. To request a copy of these timelines, you may call the customer service department toll free at 844-337-3700 or for the hearing and speech impaired TTY: 888-515-4065.