CurrentSharp-Health-PlanPolicy N/A

SHP Claims Prior Authorization and Level One Guidelines

Establishes Sharp Health Plan's guidelines and procedures for processing claims that may require prior authorization, including Level One approvals and use of Division of Financial Risk determinations; applies to Plan claims processors and related departments for Sharp Health Plan HMO/ POS products in California.

Policy Summary

PayerSharp-Health-Plan

PolicySHP Claims Prior Authorization and Level One Guidelines

Policy CodePolicy N/A

Change TypeAdministrative revisions (historical updates)

Effective DateN/A

Next Review DateN/A

Key ActionClaims Processor checks DOFR, then Attachment A and B; approve if Level One, link prior authorization to claim or route to Care Manager for review if required.

SourceLink

POLICY UPDATE CHANGES

PAR List now reflect new/updated CPT codes, services and procedures.

Reviewed and Revised for HealthEdge.

Multiple historical updates to Level One and Prior Authorization attachments (coded procedures, notifications, direct referrals, and NCB footnotes).

2attachments

Plan HMO, Individual HMO, POSproduct lines

Attachment ALevel One list

>50listed services

2018-01-27most recent revision

Coverage and Authorization Criteria

Claims authorization decision criteria

Attachment A (Level One Approval List) and Attachment B (Prior Authorization Guidelines) designate coverage/authorization requirements per service and code.

Claims Processor follows this decision order: check Division of Financial Risk (DOFR) determination; consult Attachment A (Level One Approval List); if not Level One, consult Attachment B (Prior Authorization Guidelines).

Direct with limited initial treatments: If a service is designated D,P (Direct for initial evaluation and limited visits; P for additional treatments) -> approve initial evaluation and the specified initial treatment set without prior authorization, require prior authorization for further treatments. Examples: Physical/Occupational Therapy and other rehab services: Direct referral for eval & 12 treatments; Vestibular/Balance Rehab: eval & 12 treatments; Cardiac Rehab: eval & 12 treatments.

Non-contracted or out‑of‑network providers: services from non‑contracted providers generally require prior authorization (except emergency and certain UR/ER exceptions).

Extracted coverage/authorization nodes

Service-level coverage/authorization notes extracted from Attachment A and the Prior Authorization Guide (partial list).

Acupuncture (97810-97814): marked 'P' — covered only if member has acupuncture coverage under the medical benefit and must be referred to American Specialty Health (ASH) by a PCP; other acupuncture services only if rider purchased.

Ambulance services: Emergent ambulance (A0021-A0999) marked 'X' -> no prior authorization; Non‑emergent gurney/wheelchair ambulance (A0021-A099 including A0080, A0130, A0210, A0390, A0998) marked 'P' when out‑of‑network -> prior authorization required.

Audiometry diagnostic (92557-92596): marked 'P' -> prior authorization required.

Balance/Vestibular Rehab: marked 'D,P' -> Direct referral for evaluation and 12 treatments; prior authorization required for additional treatments.

Cardiac Rehabilitation (93797-93798): marked 'D,P' -> Direct referral for evaluation and 12 treatments; prior authorization required for additional treatments.

Physical/Occupational Therapy (97003-97004 and other PT/OT entries): marked 'D,P' -> Direct referral for evaluation and 12 treatments; prior authorization required for further treatments.

Coverage nodes (JSON-encoded CriteriaNode)

Selected entries and their coverage/authorization stance from the Prior Authorization Guide expressed as criteria nodes.

Lefort I, II, III (21141-21160, 21345-21348, 21421-21436, 61586): marked 'P' — prior authorization required.

Liver Transplant (47133-47147): marked 'P' — prior authorization required.

Lung Transplant (32850-32856): marked 'P' — prior authorization required.

Lenses Status Post Cataract (92071-92072): marked 'D' — direct/in‑network (approve when in‑network conditions met).

Newborns (birth through 31 days): marked 'X' — Level One approve all services until enrolled with a medical group.

Orthoptic Training - Ophthalmology (92065): marked 'NCB' — not a covered benefit.

Codes, Examples, and Coding Notes

Ambulance HCPCS CodesHCPCS

A0021-A099	Ambulance services including gurney & wheelchair non-emergent transports (see notes)
A0080	Ambulance: other specified
A0130	Ambulance: mileage (per mile)
A0210	Ambulance: oxygen
A0390	Ambulance: stretcher accessory
A0998	Ambulance: other non-covered/unspecified

Acupuncture CPT CodesCPTCovered

97810	Acupuncture, initial 15 minutes
97811	Acupuncture, subsequent 15 minutes
97813	Acupuncture with electrical stimulation, initial
97814	Acupuncture with electrical stimulation, subsequent

Cardiac Rehabilitation CPT CodesCPTCovered

93797	Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring
93798	each additional session

Immunizations (Travel/Employment)CPTNot Covered

90476-90749

Travel or employment-related immunizations — not a covered benefit

Craniofacial / Lefort Reconstruction CPT CodesCPTCovered

21141-21160	Reconstruction midface Lefort I, II, III procedures
21345-21348	LeFort/craniofacial related codes
21421-21436	Maxillofacial reconstruction codes
61586	Craniofacial procedure code

Radiation / Proton Beam CodesCPTCovered

All	Radiation treatments (in-network) — see radiation treatments section; includes proton beam as applicable

Provider and Claims Processor Actions

Prior Authorization

Claims prior authorization determination workflow

When a claim is received the Claims Processor must: check the appropriate Division of Financial Risk (DOFR); review Attachment A (Level One Approval List) to see if the service meets Level One criteria and approve without prior authorization if it does; if not Level One, review Attachment B (Prior Authorization Guidelines) to determine whether prior authorization is required, link existing prior authorizations to the claim, route to Care Manager for medical review when records are attached and no authorization exists, or deny the claim when a prior authorization is required but no authorization or medical records are attached. All retro approvals must be linked to claims.

Check DOFR first and forward misdirected claims per SHP misdirected claims forwarding guidelines.
Approve payment without prior authorization if Attachment A indicates Level One criteria are met.
If not Level One, use Attachment B to determine PA requirements; link existing PA to claim.
If PA required and no authorization in Care Manager but medical records attached → open issue and route to Care Manager for review.
If PA required and no authorization and no medical records attached → deny the claim.
Link all retro approvals to the claim.

Key Terms and Abbreviations

Date of Receipt

DefinitionDate of Receipt: The working day when a claim, by physical or electronic means, is first delivered to Sharp Health Plan Claims Processing.

Applies toAll claims submitted to Sharp Health Plan Claims Processing (electronic or physical).

Use in workflowEstablishes the working-day timestamp for claim intake and subsequent processing steps.

Level One Criteria

DefinitionLevel One Criteria: Approving services without a prior authorization, direct referral, or notification.

Document locationAttachment A (Level One Approval List) indicates services meeting Level One criteria.

Policy Summary

PayerSharp-Health-Plan

PolicySHP Claims Prior Authorization and Level One Guidelines

Policy CodePolicy N/A

Change TypeAdministrative revisions (historical updates)

Effective DateN/A

Next Review DateN/A

Key ActionClaims Processor checks DOFR, then Attachment A and B; approve if Level One, link prior authorization to claim or route to Care Manager for review if required.

SourceLink

On This Page

Lymphedema - Decongestive Physiotherapy: marked 'P' -> prior authorization required; initial approval will be evaluation plus 8 to 10 treatments (document shows Eval + 8 to 10 / Eval + 10 in different entries).

Immunizations: Travel/Employment immunizations (90476-90749) marked 'NCB' -> not a covered benefit; In‑network adult immunizations (90476-90749) indicated 'X' -> no prior authorization required when in‑network.

CPAP/BiPAP supplies over $250: marked 'P' -> prior authorization required for supplies over $250.

Physical Therapy (D,P): direct referral for eval & 12 treatments; prior authorization required for further treatments.

Neurostimulator Pulse Generators (95970-95975) and other neuromodulation entries: marked 'P' — prior authorization required.

Observation over 48 hours (all observation services over 48 hours): marked 'P' — prior authorization required.

Documentation Required

Attachment A Level One coding indicators

Attachment A marks services with one of four indicators: X (no prior authorization or referral form needed), D (Direct/referral/notification), P (Prior Authorization required) and NCB (Not a Covered Benefit).

Examples in Attachment A include Ambulance (Emergent) marked X and non-emergent gurney/wheelchair ambulance marked P (out-of-network).
Attachment A entries show D for in‑network/direct items (e.g., amniocentesis) and P for procedures requiring PA (e.g., diagnostic audiometry).

Prior Authorization

Prior Authorization Guide legend

Legend used in the Prior Authorization Guide: P = Prior Authorization Required; D = Direct (direct referral allowed); X = No prior authorization or referral form needed; NCB = Not a Covered Benefit.

These definitions are applied throughout Attachment A and Attachment B to indicate authorization requirements.

Step Therapy

Direct referral with limited sessions

Certain rehabilitation services may be initiated via direct referral for an evaluation plus a limited number of treatments (commonly an eval and 12 treatments); prior authorization is required to continue treatment beyond that initial set.

Balance (vestibular) rehab: Direct referral for evaluation and 12 treatments; PA required for further treatments.
Cardiac rehabilitation: Direct referral for evaluation and 12 treatments; PA required for further treatments.
Physical/Occupational/Hand Therapy: Direct referral for evaluation and first 12 treatments; PA required for continuation.

Prior Authorization

Authorization key/legend

The authorization key repeated in the guide emphasizes: P = Prior Authorization Required; D = Direct; X = No prior authorization or referral form needed; NCB = Not a Covered Benefit.

This key is the authoritative legend for interpreting Attachment A and Attachment B entries.

Note

Examples of authorization designations

Attachment entries include many specific services labeled P, D, X or NCB; examples shown in the guide include Liver Transplant (P), Lenses status post cataract (D/In‑Network), Newborns (X) and Orthoptic Training (NCB).

Use the designation on the specific Attachment A/B line item to determine approval, direct referral handling, PA requirement or not‑covered status.
Examples: Lymphedema decongestive physiotherapy is P with initial approval Eval + 8–10; many transplant and reconstruction procedures are P.

Prior Authorization

Therapy referral and prior auth workflow

Physical, Occupational, Pool (Aqua) and Pulmonary Rehabilitation therapies may be approved by direct referral for an initial evaluation plus up to 12 treatments; prior authorization is required for continuation beyond those initial visits.

Therapies are marked D,P in the guide: direct referral for eval & 12 treatments, PA required for further treatments.
Apply this workflow when processing therapy claims—approve initial set per Attachment A/B and require PA for additional units.

ExamplesIncludes items such as contracted ambulance emergent services and newborn services (birth through 31 days) when specified in Attachment A.

Prior Authorization

DefinitionPrior Authorization: Approval given for treatment or care prior to the services being rendered; authorization must be recorded in HealthEdge.

System requirementAuthorizations must be entered in HealthEdge to be valid per policy definitions.

Workflow impactIf a service is marked 'P' in the guides, claims processors must link an existing prior authorization to the claim or route to Care Manager for review if records are attached; deny if PA missing and no records attached.

Division of Financial Risk (DOFR)

DefinitionDivision of Financial Risk (DOFR): The financial risk agreement between Sharp Health Plan and another entity.

Use in claims processingClaims Processor checks DOFR to determine contractual/financial responsibilities prior to applying Attachment A/B rules.

Applies toAgreements with other entities that affect authorization and payment routing.

MeaningP = Prior Authorization Required.

Where usedShown in Attachment A and the Prior Authorization Guide to indicate services that require approval before rendering.

Workflow noteIf a service is marked 'P', claims must have the PA linked in HealthEdge or be routed for medical review per policy procedures.

MeaningD = Direct (direct referral allowed).

ImplicationDirect referrals from contracted physicians permit services (often an evaluation plus limited treatments) without a separate referral form.

ExamplesUsed for in-network services such as Lenses Status Post Cataract and certain brachytherapy procedures (noted as D in attachments).

MeaningX = No prior authorization or referral form needed.

ExamplesApplied to services such as emergent ambulance and in-area emergency services listed in Attachment A/B.

ScopeLevel One-approved services commonly carry an 'X' designation in the guide.

NCB

MeaningNCB = Not a Covered Benefit.

ExamplesItems such as tubal ligation reversal are explicitly marked NCB in the Prior Authorization Guide.

ActionClaims for services marked NCB should be processed as not covered per the guide entries.

Prior Authorization Required

ShorthandP — Prior Authorization Required (see Prior Authorization Guide).

UsageUsed throughout Attachment A and the Prior Authorization Guide to flag services requiring pre-approval.

System noteAuthorizations must be present in HealthEdge to satisfy 'P' requirements.

Direct (In-Network / direct referral)

ShorthandD — Direct (In-Network / direct referral).

ImplicationDirect referrals allow certain evaluations and initial treatment sessions without a separate prior authorization form.

ExampleDirect designation is shown for in-network maternal-fetal services and lens status post cataract entries.

No prior authorization or referral form needed

ShorthandX — No prior authorization or referral form needed.

Typical useMarks emergent and other Level One services that can be approved on claim receipt without prior authorization.

Processing noteClaims processors should verify Attachment A/B entries for 'X' designations when routing claims.

Not a Covered Benefit

ShorthandNCB — Not a Covered Benefit.

ApplicationServices explicitly marked NCB in the Prior Authorization Guide are not payable under covered benefits.

ExampleOrthoptic training and tubal ligation reversal are listed as NCB in the guide.