Prior authorization timeframes and notifications

A decision will be rendered on all prior authorization requests: urgent services (including in‑area urgent care) will be decided as soon as appropriate for the member's condition but no later than 72 hours from receipt (and necessary information); non‑urgent requests will be decided as soon as appropriate but no later than five (5) business days from receipt (and necessary information). The treating provider is notified within 24 hours and followed by written notice; members are notified within two (2) business days.

Services requiring prior authorization (summary)

Many services require prior authorization as described in the benefit descriptions, including outpatient and inpatient surgery, advanced diagnostic imaging (CT/MRI/PET), genetic testing, certain mental health/residential services, home infusion, TMS, ECT, partial hospitalization and intensive outpatient programs.

Prior Authorization Requirements (summary)

Prior authorization is required for Skilled Nursing Facility services, Home Health Care, Home Infusion Therapy and other services that have day/visit limits; providers must obtain authorization before services are rendered.

Prior Authorization Process

Providers (typically the PCP or specialist) must request prior authorization from the Member's medical group or Scripps Health Plan for services that require approval; providers usually contact Scripps Health Plan to obtain authorization and must ensure authorizations are obtained before services are provided.

ASH Plans prior authorization

For acupuncture and chiropractic benefits provided through ASH Plans, the practitioner (or provider) initiates authorizations by contacting American Specialty Health Plans of California, Inc. (ASH Plans).

• Contact ASH Plans at 1-800-678-9133 for authorization/authorization initiation.

Evernorth BH prior authorization

All non‑emergency inpatient mental health admissions and certain outpatient MH/SUD services require prior authorization through Evernorth Behavioral Health (Evernorth BH); providers should contact Evernorth BH for prior authorization and network arrangements.

• Evernorth BH prior authorization phone: 1-888-736-7009.
• All non‑emergency MH/SUD services must be arranged through Evernorth BH and delivered by Evernorth BH Participating Providers.

Exceptions to prior authorization

Prior authorization is NOT required for specified services including family planning (including abortion and FDA‑approved contraceptives), vasectomy, preventive care (immunizations, annual physicals), basic prenatal care, STD services, HIV testing, and FDA‑approved biomarker testing for members with advanced/metastatic stage 3 or 4 cancer.

Prior Authorization Responsibilities (PCP obligations)

The member's PCP is responsible for obtaining prior authorization before hospital or skilled nursing facility admissions (including sub‑acute care), before home health care, and for certain other services; mental health and substance use services follow the Evernorth BH process and emergency admissions do not require prior authorization.

• PCP arranges admissions and requests authorization when indicated.
• Emergency admissions are excepted from prior authorization requirement.

Post-Stabilization Authorization and Transfer

Contracted and non‑contracted hospitals must timely notify Scripps Health Plan once a patient is clinically stable so the Plan can authorize post‑stabilization care or arrange transfers; if authorization/transfer is not arranged and the member refuses transfer, the hospital must notify the patient they may be financially responsible for subsequent services.

• Hospitals must contact the Plan for post‑stabilization prior authorization or to arrange transfer.
• If the non‑Plan hospital cannot contact the Plan to request authorization, it may bill the member for such services.

Expedited Decision Process

Scripps Health Plan and Evernorth BH provide an expedited decision process: members, physicians, or representatives may request expedited decisions (including appeals) when routine processing may jeopardize life or health; Scripps and Evernorth must decide and notify as soon as possible but no later than 72 hours from receipt, and physicians are notified within 24 hours of the decision.

• Expedited decision timeframe: not to exceed 72 hours.
• Physicians notified within 24 hours of an expedited decision.

Evernorth BH expedited decision process

Evernorth BH supports an expedited behavioral health decision process: members, physicians, or representatives may request expedited BH decisions when routine processing might jeopardize life/health or in cases of severe pain or suspected improper enrollment action; Evernorth BH will decide and notify within 72 hours.

• Contact Evernorth BH at 1-888-736-7009 for expedited behavioral health review.

Inpatient SUD detox prior authorization

Medically necessary inpatient SUD detoxification services are covered when the member is admitted through the emergency room or when prior authorized.

Infertility prior authorization

Prior authorization is required for services related to infertility and assisted reproductive technologies; infertility services covered only when criteria are met and prior authorization is obtained.

• Infertility coverage requires documented cause of infertility per specialty evaluation and FSH threshold criteria where applicable.
• Prior authorization is required before services will be covered.

Infertility prior authorization (reminder)

Prior authorization is required for infertility and assisted reproductive technologies (see benefit criteria); providers must obtain authorization before providing covered infertility services.

Non-emergency ambulance and home health prior authorization

Non‑emergency ambulance transfers (including transfers from non‑Plan to Plan hospitals, between Plan facilities, and facility‑to‑home transfers when an ambulance is medically necessary) and home health services require pre‑authorization.

Authorization for follow-up after non-Plan emergency care

Follow‑up care after emergency services received at a non‑Plan hospital must be authorized by Scripps Health Plan or it may not be covered; the non‑Plan hospital must contact the Plan for authorization for continued services once the member is stabilized.

• If the non‑Plan hospital cannot identify Plan contact information and request authorization, it may bill the member.
• Members improperly billed should contact Scripps Health Plan at 1-844-337-3700 or TTY 1-888-515-4065.

Home Health Prior Authorization

Home health services are covered when medically necessary, must be ordered by the PCP, are limited to covered professional providers listed (RN, LVN, certified home health aide with skilled service, MSW, PT/OT/ST), have a benefit limit (up to 120 days per member per calendar year), and require prior authorization.

• Ensure PCP orders and obtains prior authorization before initiating home health services.
• Home health benefit excludes medications covered under the Prescription Drugs section.

Home Infusion / Hemophilia Prior Authorization and Provider Requirement

Home infusion and hemophilia home infusion products and services require prior authorization and must be provided by participating/home infusion agencies or participating Hemophilia Infusion Providers; hemophilia services require Plan prior authorization and must be provided by participating Hemophilia Infusion Providers.

• Home infusion: provided by a home infusion agency and prior authorized when medically necessary.
• Hemophilia: participating Hemophilia Infusion Provider required; blood factor products require Plan approval following physician evaluation.

Prescription Drug Prior Authorization

Many formulary, non‑formulary, step therapy, and specialty drugs require prior authorization; routine pharmacy PA decisions are issued within 72 hours from receipt of required information and expedited PA decisions within 24 hours. Providers or members request pharmacy prior authorization by submitting the Pharmacy Prior Authorization form (to MedImpact via fax 1-858-790-7100).

• Routine pharmacy PA decision timeframe: 72 hours after receipt of required information.
• Expedited pharmacy PA (exigent) decision timeframe: 24 hours.

Opiate Quantity Prior Authorization

Certain opiate classes/doses/combinations may require prior authorization when the 90‑day quantity exceeds thresholds considered unsafe by the pharmacist; if the pharmacy deems an opiate quantity above the threshold medically necessary, the provider may need to submit a PA documenting medical necessity.

• Opiate quantity PA applies when 90‑day quantity exceeds pharmacist‑determined safety thresholds.

Pharmacy prior authorization and step therapy

Certain formulary drugs, most specialty drugs, select contraceptives, select non‑formulary drugs, and some compounded drugs require prior authorization; step therapy may be required where the Formulary indicates. Providers must submit prior authorization or step therapy requests using the Pharmacy Prior Authorization form; MedImpact reviews PA/Step Therapy requests and issues decisions per the specified timelines.

• Compounded drug coverage conditions are listed in the Pharmacy section (active ingredient, no appropriate FDA‑approved alternative, self‑administered, FDA indication).
• Submit PA to MedImpact via fax: 1-858-790-7100.

Opiate quantity prior authorization (thresholds)

Certain opiate classes/doses/combinations may require prior authorization if the 90‑day quantity exceeds pharmacist‑determined safety thresholds; providers may need to submit supporting medical necessity documentation with the PA.

Behavioral health inpatient prior authorization

All non‑emergency inpatient mental health and substance use disorder services, including residential care, must be prior authorized by Evernorth BH; prior authorization and authorization requests for MH/SUD services are handled by Evernorth BH and its Participating Providers.

• Call Evernorth BH for prior authorization at 1-888-736-7009.

Transplant prior authorization and facility requirement

Special transplant benefits require prior written authorization from the Plan Medical Director and must be performed at a Scripps‑approved Transplant Network Facility; failure to obtain prior written authorization or to use an approved facility will result in denial of claims.

• Plan Medical Director reviews all transplant PA requests; contact Customer Service for the approved Transplant Network.

Transplant prior authorization and facility restriction

Prior written authorization from the Plan Medical Director is required for Special Transplant Benefits; evaluation, transplantation and follow‑up must be performed at Scripps‑approved Transplant Network Facilities or claims will be denied.

Diabetes self-management training precertification

Diabetes outpatient self‑management training is covered when medically necessary and authorized; precertification (preauthorization) is required after six (6) visits.

• Obtain authorization before or at start of services and ensure precertification once the member exceeds six visits.

Clinical trial routine care authorization

Members accepted into an approved clinical trial may receive routine patient care services if prior authorized through the member's medical group and the trial/hospital meets Plan provider requirements.

• Prior authorization is required for routine patient care in approved clinical trials.

Dialysis authorization and geographic limitation

Chronic dialysis (peritoneal or hemodialysis) must be authorized by the member's medical group or Scripps Health Plan and provided within the member's medical group; chronic dialysis maintenance outside the member's medical group is not covered for travel.

• Obtain authorization through the member's medical group or Scripps prior to chronic dialysis arrangements when required.

Prior authorization for out-of-network necessary services

Prior authorization is required when medically necessary services are not available within the assigned primary care medical group and out‑of‑network care is sought; providers should obtain prior authorization before arranging out‑of‑network services.

PCP authorization/telephone access

The member's PCP must provide telephone access 24 hours a day, 7 days a week to assist members and provide prior approval of medically necessary care when required.

• Providers must ensure PCP availability for after‑hours access and prior approval coordination.

Utilization Review disclosure and access

Utilization Review process documentation is available on request; providers and members may request the Utilization Review description from Customer Service, and for behavioral health utilization review contact Evernorth BH.

• Customer Service: 1-844-337-3700; Evernorth BH for BH UR: 1-888-736-7009.

Reinstatement and Cancellation

Reinstatement and cancellation procedures for group coverage refer members and employers to the Group Agreement and the employer HR Benefits Manager; no benefits are provided for services after the effective date of cancellation except as specified under Extension of Benefits and COBRA.

Prior Authorization (definition)

Prior Authorization is defined as a requirement that the member or prescribing provider obtain authorization for a service or prescription drug before the Plan will cover it; the Plan shall grant prior authorization when it is medically necessary.

Exception Request for Prescription Drugs

An Exception Request is a request for coverage of a prescription drug and must be submitted through the Pharmacy Prior Authorization form (Pharmacy PA process).

• Pharmacy Exception Requests/Step Therapy exceptions use the Pharmacy Prior Authorization form submitted to MedImpact.

External Exception Review (member option)

If Scripps Health Plan denies, modifies, or delays a health care service or treatment, a member may request an External Exception Review (independent review) to obtain an objective review performed by physicians unaffiliated with the Plan.

• External review timeframes and appeal rights are provided in the Appeals and External Review sections.

Pharmacy prior authorization and step therapy (specialty drugs)

Specialty drugs may require prior authorization for medical necessity and, when designated, must be obtained from a Scripps Health Plan specialty pharmacy; all requests for Step Therapy must be submitted using the Pharmacy Prior Authorization form.

• Specialty dispensing rules: specialty drugs are listed in the Outpatient Drug Formulary and may require specialty pharmacy dispensing.