Prior authorization decision timeframes and notifications

A decision will be rendered on prior authorization requests within 72 hours for urgent services and no longer than five (5) business days for other services; the treating provider will be notified of the decision within 24 hours followed by written notice, and Members will be notified within two (2) business days of the decision.

Examples of services requiring prior authorization

Prior authorization is required for many services, including inpatient and outpatient surgery, non-emergent inpatient admissions, advanced diagnostic imaging (CT, MRI, PET), transplant services, bariatric surgery, certain behavioral health services (inpatient, partial hospitalization, intensive outpatient, home-based autism services), and provider-administered injectable medications and DME.

Prior authorization for certain services

Prior authorization is required for Skilled Nursing Facility services and for Home Health Care and Home Infusion Therapy as indicated in the benefit descriptions; these services require PCP order and authorization and are limited by the stated day maximums.

• SNF: 100 day maximum per member per calendar year; prior authorization required.
• Home Health Care: up to 120 days per member per calendar year; must be ordered by the PCP and prior authorized.
• Home Infusion Therapy: covered when prescribed by the PCP and prior authorized; provided by a home infusion agency.

Prior authorization responsibilities and list

Providers—typically the member's PCP—are responsible for requesting prior authorization for specified services; Scripps maintains a list of services requiring prior authorization and providers may contact utilization management for criteria and authorization requests.

• Physician usually contacts Scripps Health Plan to obtain prior authorization.
• Providers can contact Scripps utilization management or Customer Service to obtain authorization criteria and the list of services requiring authorization.

Denial notification and member rights

If a request is denied or not fully approved, the written notification will state the action taken and reasons, include appeal rights and instructions, advise the right to request review by a different qualified health professional, and explain how to request continuation of benefits during an appeal.

• Notification will explain the reason for denial and the appeals process.
• Members may request expedited resolution and request benefits continue pending appeal.

Standing referrals

Standing referrals may be issued when the PCP and specialist determine ongoing specialist care is necessary; such referrals are part of a treatment plan and may be limited by number of visits or time period.

• Referral will generally be to a participating Plan provider unless prior authorization is obtained to see an out-of-network specialist.
• Decisions on standing referrals will be made within three (3) business days if complete information is provided.

Acupuncture and chiropractic prior authorization

Prior authorization for acupuncture and chiropractic benefits is coordinated through ASH Plans; members may self-refer to ASH network practitioners, and the practitioner will contact ASH Plans to initiate authorization when a treatment plan requires it.

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

MH inpatient prior authorization

Prior authorization is required for all non-emergency mental health inpatient admissions and residential care; providers should call Magellan at least five (5) business days prior to admission—Magellan will render urgent decisions within 72 hours and other decisions within five business days, with provider and member notifications as specified.

• Call Magellan at 1-866-272-4084 at least five (5) business days prior to a scheduled non-emergency admission.
• Urgent decisions: not to exceed 72 hours; other decisions: within five (5) business days; treating provider notified within 24 hours and written notice to provider and member within two business days.

Prior authorization for mental health admissions

Prior authorization is required for all non-emergency Mental Health Hospital inpatient admissions (acute inpatient and Residential Care); providers must call Magellan and follow Magellan's authorization process prior to admission.

• Magellan handles prior authorization for MH/SUD services and maintains expedited decision procedures.

Emergency admission exception

Prior authorization is not required for an emergency admission.

Prior authorization for non-mental-health services

PCPs are responsible for obtaining prior authorization for inpatient medical-surgical admissions, home health care, skilled nursing facility (including sub-acute) admissions, hospice admissions, and certain other services—mental health/SUD prior authorization is handled by Magellan.

• PCP arranges admissions and requests authorization for hospital, SNF, home health, and hospice services.
• Mental health/substance use disorder services use Magellan for prior authorization and provider network.

Expedited decisions (medical and mental health)

An expedited decision process is available when routine processing might seriously jeopardize life or health, for severe pain, or similar exigent circumstances; Scripps (and Magellan for MH/SUD) shall decide and notify the Member as soon as possible but not to exceed 72 hours, and physicians will be notified within 24 hours of the decision.

• Concurrent care will not be discontinued until the provider has been notified and agrees with a plan of care.
• Contact Scripps Customer Service at 1-844-337-3700 or Magellan at 1-866-272-4084 for expedited decision information.

Expedited Decisions

Members, physicians, or representatives may request an expedited decision when routine processing might seriously jeopardize life/health or for severe pain; Scripps will make a decision and notify the member within 72 hours and will notify physicians within 24 hours.

Behavioral Health Expedited Decisions via Magellan

Magellan administers mental health and substance use disorder services and provides an expedited decision procedure for behavioral health authorizations with decision and notification within 72 hours; providers and members should contact Magellan for behavioral health authorizations and expedited requests.

• Magellan phone: 1-866-272-4084 (TTY: 711).

Advanced Imaging Coverage

Advanced imaging services (CT, MRI, PET) are covered when used to diagnose illness or injury; complex imaging is covered on an outpatient basis and may require prior authorization as indicated in the Summary Benefit Description.

• Complex imaging expenses for preoperative testing are payable under this benefit.
• Advanced diagnostic imaging noted in Summary Benefit Description requires prior authorization.

Genetic/Biomarker Testing

Genetic and biomarker testing are covered when medically necessary and expected to influence monitoring or treatment decisions; effective July 1, 2024, medically necessary biomarker testing is covered, and prior authorization is not required for members with advanced/metastatic stage 3 or 4 cancer per the Summary Benefit Description.

• Genetic testing must be expected to lead to altered monitoring or treatment and be medically necessary per Scripps medical policy.
• Biomarker testing: effective July 1, 2024, covered when medically necessary; no prior authorization required for stage 3 or 4 advanced/metastatic cancer.

Breast Pump/DME Procurement

Breast pump rental or purchase is covered only if obtained from a designated Plan provider; coverage is limited to one pump per pregnancy and to specific models from the Plan's capitated DME vendor; heavy‑duty hospital‑grade pump rental is covered only for defined clinical scenarios.

• No copay for breast pumps and related lactation supplies when obtained from a designated Plan provider.
• Heavy-duty pump rental covered for NICU confinement, mother/infant separation, infant/maternal medical conditions; not covered for convenience.

Prior Authorization and Authorization for Continued Care

Prior authorization is required for infertility services and for home health services; non‑Plan hospitals providing post‑stabilization care must contact Scripps Health Plan for authorization to continue care.

• Infertility services covered only with prior authorization and when outpatient criteria (including FSH <19 miU on day 3) are met.
• Non-Plan hospital follow-up care after emergency services must be authorized by Scripps or may not be covered.

Authorization for Ambulance and Post-Emergency Care

Non-emergency ambulance transfers require pre-authorization; follow-up care after emergency services from a non‑Plan hospital must be authorized by Scripps Health Plan or it may not be covered.

• Medically necessary ambulance transfers between facilities require pre-authorization.
• If non-Plan hospital cannot contact Scripps for authorization, the hospital may bill the member.

Home Health Prior Authorization

Home Health services require prior authorization and must be ordered by the PCP; covered professional providers include RN, LVN, certified home health aide (with skilled service), medical social worker, PT/OT/SLP, and supplies used during covered visits are included.

• Benefit limited to up to 120 days maximum per member per calendar year.
• Medications and drugs covered under Prescription Drugs section are excluded from this benefit.

Infusion and PKU Prior Authorization

PKU-related formulas, most home infusion/IV injectable therapies, and hemophilia products require prior authorization; hemophilia products must be provided by a participating Hemophilia Infusion Provider and follow Plan approval procedures.

• PKU formulas and special food products must be prior authorized and prescribed by an appropriate clinician; PKU formulas covered under Prescription Drugs section.
• Home infusion therapy covered when provided by a home infusion agency, prescribed by PCP and prior authorized; excludes medications covered under Prescription Drugs.

Drug Prior Authorization Timelines

Select formulary, non-formulary, step therapy, and most specialty drugs require prior authorization; routine pharmacy prior authorization decisions are issued within 72 hours and expedited pharmacy decisions within 24 hours for exigent circumstances.

• Submit prior authorization and supporting documentation to MedImpact via fax at 1-858-790-7100.
• Routine pharmacy prior authorization decisions: within 72 hours; expedited (exigent) decisions: within 24 hours.

MedImpact Prior Authorization Process

MedImpact manages prior authorization and step therapy determinations for drugs; providers must submit the Prior Authorization form with supporting medical documentation to MedImpact for review.

• MedImpact fax for prior authorization: 1-858-790-7100.
• MedImpact will review requests and make approval/denial determinations within stated timeframes.

Opiate Quantity Prior Authorization

Opiate quantities above a pharmacist-defined safety threshold for the last 90 days may require prior authorization; if pharmacy staff deems the quantity above the threshold medically necessary, the provider may need to submit a prior authorization to support medical necessity.

• Thresholds are applied when the last 90-day quantity exceeds the pharmacist's professional safety threshold.
• Provider may submit prior authorization to support medical necessity for quantities above the threshold.

Pharmacy prior authorization and step therapy

Prior authorization is required for certain formulary drugs, most specialty drugs, select contraceptives, and select non‑formulary drugs; Step Therapy is required where indicated on the Formulary and exceptions or prior authorization requests must be submitted using the Pharmacy Prior Authorization form.

• Compounded drugs covered only if specific conditions are met; if approved, Non‑Formulary Brand Name Drug Copayment applies.
• Appeals and exception requests follow the Plan's pharmacy appeal timelines (standard 30 days; expedited 72 hours).

BH inpatient prior authorization

All non-emergency inpatient mental health and substance use disorder services, including residential care, must be prior authorized by Magellan and obtained from Magellan Participating Providers.

• Contact Magellan at 1-866-272-4084 (TTY: 711) for prior authorization and network information.

Opiate quantity prior authorization

Opiate quantity thresholds may trigger prior authorization when 90‑day quantities exceed pharmacist safety thresholds; providers may submit prior authorization to support medical necessity for quantities above the threshold.

Transplant prior authorization and facility requirement

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

• Contact Customer Service at 1-844-337-3700 for information on Scripps-approved Transplant Network Facilities.
• Pre-transplant evaluation, transplantation and follow-up are allowed only at approved Transplant Network Facilities with prior authorization.

Diabetes self-management training precertification

Precertification is required after six (6) visits for diabetes outpatient self-management training; continued coverage is contingent on medical necessity and authorization.

• Diabetes self-management training includes instruction and education to enable proper device use and daily management.

Prior authorization for out-of-network and specific services

Prior authorization is required for certain out‑of‑network medically required services not available within the assigned PCP medical group; prior authorization is also required for services that otherwise require prior authorization (specialists, MHSA-arranged MH/SUD services).

• Out‑of‑network medically necessary services require prior authorization before obtaining the service.

Utilization Review disclosure and access

The Utilization Review process is documented and available to Members and providers; to request a copy of the Utilization Review documentation or information about behavioral health/SUD utilization review, contact Scripps Customer Service or Magellan.

• Scripps Customer Service: 1-844-337-3700 (TTY: 1-888-515-4065).
• Magellan (Behavioral Health Utilization Review): 1-866-272-4084 (TTY: 711).

Prior Authorization definition

Authorization (Prior Authorization) is defined as approval of a request for covered medical services issued in response to a prior authorization request; Prior Authorization is a requirement that the Member or prescribing provider obtain authorization before the Plan will cover the service or drug, and the Plan shall grant prior authorization when it is medically necessary.

Prior Authorization

Prior Authorization is a requirement that the Member or the prescribing provider obtain an authorization for a service or prescription drug before the Plan will cover the service or drug; the Plan grants prior authorization when it is medically necessary.

Exception Request (pharmacy)

If an enrollee or prescribing provider submits an exception request for a prescription drug and it is determined to be medically necessary, the Plan must cover the prescription drug; exception requests and step therapy exceptions must be submitted using the Pharmacy Prior Authorization form.

• Exception requests use the Pharmacy Prior Authorization form and, if approved, the drug will be covered as medically necessary.

Specialty Drug Prior Auth / Pharmacy Requirement

Specialty drugs may require prior authorization for medical necessity and must be obtained from a Scripps Health Plan specialty pharmacy; specialty drugs are listed in the Outpatient Drug Formulary and may have special handling or limited prescribing availability.

• Specialty drugs may require prior authorization and must be obtained from a Scripps specialty pharmacy; they are managed via MedImpact and the specialty pharmacy program.

Pharmacy prior authorization and step therapy

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