The Sharp prior authorization form is the Prior Authorization/Precertification Form your doctor submits to Sharp Health Plan to get approval before performing certain covered services. It applies to HMO, PPO, and POS members and works for in-network and out-of-network requests. Your provider faxes it to 1-619-740-8111 or submits it through the Sharp Health Plan Provider Portal.1Sharp Health Plan. Medical Prior Authorization
Which Form Applies to You
Sharp uses two versions. PPO and POS members have the POS/PPO Precertification Form. HMO members use a separate referral and prior authorization form.2Sharp Health Plan. Prior Authorization / Precertification Both are downloadable PDFs and collect the same core information.
Whether your specific service needs approval depends on the current authorization list. Sharp publishes separate lists for HMO members and for PPO/POS members on its provider resources page, and splits services into two tiers: those needing full prior authorization before scheduling, and those needing only advance notification.3Sharp Health Plan. Referral and Prior Authorization Request Form The lists change, so your provider should check the current version before scheduling.
What Goes on the Form
Member and Provider Information
The top of the form asks for your full name exactly as it appears on your Sharp member ID card, along with your member ID number. Your provider adds their National Provider Identifier (NPI), Tax Identification Number (TIN), contact details, and the address of the facility where the service will be performed. Sharp uses these to verify network status and match the request to your account.
Diagnosis and Procedure Codes
The clinical section needs ICD-10 codes for your diagnosis and CPT or HCPCS codes for the procedure, service, or equipment. A mismatch between the diagnosis and procedure codes is one of the most common reasons a request gets kicked back. For durable medical equipment or injectable drugs, the HCPCS code carries the specifics on item and dosage.
Clinical Documentation
Sharp’s guidance is to include anything that supports the request, such as chart notes, imaging results, or lab data.1Sharp Health Plan. Medical Prior Authorization In practice, more documentation means faster review. Recent progress notes, imaging reports, and labs that explain why the service is necessary let the review team decide without coming back for more. Missing documentation is the other major reason requests stall.
How Your Provider Submits It
There are two channels for medical requests:
- Fax the completed form and supporting documents to 1-619-740-8111.3Sharp Health Plan. Referral and Prior Authorization Request Form
- Submit and track electronically through the Sharp Health Plan Provider Portal at sharphealthplan.com/login.1Sharp Health Plan. Medical Prior Authorization
Pharmacy prior authorization is different. Prescription drug requests use their own form faxed to 1-888-836-0730 for Commercial and CalChoice members, or 1-855-245-2134 for Covered California members. Pharmacy requests also need their own supporting information, including symptoms, dated lab results, and justification for the therapy or dosage.4Sharp Health Plan. Pharmacy Prior Authorization
How Long Sharp Has to Decide
California law sets the clock. For routine medical requests, Sharp must issue a decision within five business days of receiving all reasonably necessary information.5California Legislative Information. California Health and Safety Code 1367.01 If the plan asks for additional documentation, the five-day window restarts when the missing information arrives.
When your condition poses an imminent and serious threat to your health, including potential loss of life, limb, or major bodily function, your provider can request an urgent review. The plan then has 72 hours to decide.5California Legislative Information. California Health and Safety Code 1367.01 Prescription drug authorizations run on a tighter clock: 72 hours for non-urgent and 24 hours for urgent.6California Medical Association. New Approval Timeframes for Prescription Drug Prior Authorizations
Once Sharp decides, both you and your provider are notified. An approval includes an authorization number tied to the specific scope, duration, and frequency of treatment.
When You Don’t Need Prior Authorization
Emergency care never requires advance approval. Under the federal No Surprises Act, a plan cannot deny coverage because you did not get authorization before going to an emergency room, even at an out-of-network facility. The protection covers emergency medical and mental health services in a hospital emergency department or a freestanding emergency facility, along with pre- and post-stabilization care.7U.S. Department of Labor. Avoid Surprise Healthcare Expenses – How the No Surprises Act Can Protect You Sharp’s own policy mirrors this: listed services do not require authorization in an emergency.1Sharp Health Plan. Medical Prior Authorization Any follow-up or ongoing services after you are stabilized still go through the standard process if they would otherwise require it.
Behavioral Health Services
Sharp does not require a referral from your primary care physician to see an in-network outpatient therapist. Whether a specific behavioral health or substance use service needs prior authorization depends on your plan and the level of care. Sharp directs members to the Member Handbook, the current Behavioral Health Guide on its website, or Customer Care at 1-844-483-9013.8Sharp Health Plan. Behavioral Health Federal parity law generally bars plans from imposing stricter authorization rules on behavioral health than on comparable medical or surgical services.
If Sharp Denies the Request
A denial notice will state the clinical reasons the request was not approved. You have 180 calendar days from the date of the denial to file a grievance or appeal with the plan. Sharp acknowledges appeals within five calendar days and resolves them within 30 calendar days.9Sharp Health Plan. File a Grievance or Appeal
You can submit by mail or in person at Sharp Health Plan, Attention: Grievances and Appeals, 8520 Tech Way, Suite 200, San Diego, CA 92123, or by fax to 1-619-740-8572. For urgent situations involving a serious health threat, call Customer Care at 1-800-359-2002. Urgent appeals get a decision within 72 hours.9Sharp Health Plan. File a Grievance or Appeal
Independent Medical Review Through the DMHC
If Sharp’s internal appeal does not resolve the issue, or 30 days pass without a resolution, you can escalate to the California Department of Managed Health Care for an Independent Medical Review. The IMR is an impartial review of the medical necessity decision by physicians unaffiliated with Sharp.10California Department of Managed Health Care. How to File a Complaint
You generally must participate in Sharp’s grievance process for at least 30 days before the DMHC will accept the case. The exception is a serious threat to your health, which the DMHC can expedite. File online at the DMHC website or by mail and fax. Standard complaints are typically resolved in about 30 days and IMR cases in about 45 days from the date the case qualifies.10California Department of Managed Health Care. How to File a Complaint The DMHC Help Center is at 1-888-466-2219.
Staying on Treatment During an Appeal
If the denial affects a continuation or renewal of a service you already receive, ask your provider whether you can continue it while the appeal is pending. California law requires plans to keep covering previously authorized services in certain situations during appeal. Keep a record of every call and letter during this period, including dates, names, and reference numbers, so you have documentation if the dispute moves to the DMHC.