Claims payment policies and practices

Qualified Health and Dental Plan Issuers have provided information to help you understand what is needed for a claim to be paid, or why a claim was denied.

Grace periods and claims pending

For members enrolled in an Individual & Family Plan through Covered California™ who are receiving federal premium assistance (also called APTC): If your premium is not received, you will enter a 90-day grace period beginning on the first day of non-payment when premium is due. During the first 30 days of this grace period, you can continue to access services, and claims for covered benefits will be paid. If you receive covered benefits during days 31 to 90, your claims will be denied unless you pay all past-due premium amounts. If you do not pay the premium due before your 90-day grace period ends, your coverage will be cancelled.

For all other members enrolled in an Individual & Family Plan: If your premium is not received, you will enter a 30-day grace period beginning on the first day of non-payment when premium is due. During this period, you can continue to access services, and claims for covered benefits will be paid. If payment is not received by the end of the 30-day grace period, your coverage will be canceled. Claims for services received after the grace period will be denied.

Retroactive denials

Sharp Health Plan does not go back and deny claims that have been previously paid.

Medical necessity and prior authorization time frames and enrollee responsibilities

Except for PCP services, outpatient mental health or chemical dependency office visits, MinuteClinic services, Emergency Services and obstetric and gynecologic services, you are responsible for obtaining valid Authorization before you receive Covered Benefits.

To obtain a valid Authorization:

Prior to receiving care, contact your PCP or other approved Plan Provider to discuss your treatment plan.

Request prior Authorization for the Covered Benefits that have been ordered by your doctor. Your PCP or other Plan Provider is responsible for requesting Authorization from Sharp Health Plan or your Plan Medical Group.

If Authorization is approved, obtain the expiration date for the Authorization. You must access care before the expiration date with the Plan Provider identified in the approved Authorization.

A decision will be made on the Authorization request in a timely fashion based on the nature of your medical condition, but no later than five business days. A letter will be sent to you within two business days of the decision.

If waiting five days would seriously jeopardize your life or health or your ability to regain maximum function or, in your doctor's opinion, it would subject you to severe pain that cannot be adequately managed without the care or treatment that is being requested, you will receive a decision in a timely fashion based on the nature of your medical condition, but no later than 72 hours after receipt of the Authorization request.

If we do not receive enough information to make a decision regarding the Authorization request, we will send you a letter within five days to let you know what additional information is needed. We will give you or your Provider at least 45 days to provide the additional information. (For urgent Authorization requests, we will notify you and your Provider by phone within 24 hours and give you or your Provider at least 48 hours to provide the additional information).

If you receive Authorization for an ongoing course of treatment, we will not reduce or stop the previously Authorized treatment before providing you with an opportunity to Appeal the decision to reduce or stop the treatment.

The Plan uses evidence based guidelines for Authorization, modification or denial of services as well as Utilization Management, prospective, concurrent and retrospective review. Plan specific guidelines are developed and reviewed on an ongoing basis by the Plan Medical Director, Utilization Management Committee and appropriate physicians to assist in determination of community standards of care. A description of the medical review process or the guidelines used in the process will be provided upon request.

If you change to a new PMG as a result of a PCP change, you will need to ask your new PCP to submit Authorization requests for any specialty care, Durable Medical Equipment or other Covered Benefits you need. The Authorizations from your previous PMG will no longer be valid. Be sure to contact your new PCP promptly if you need Authorization for a specialist or other Covered Benefits.

If services requiring prior Authorization are obtained without the necessary Authorization, you may be responsible for the entire cost.

Drug exception time frames and enrollee responsibilities (not required for SADPs)

In the event that our members need access to drugs that are not listed on the plan's formulary (drug list). These medications are initially reviewed by Sharp Health Plan through the formulary exception review process. The member or provider can submit the request to us by faxing the Pharmacy Prior Authorization and Step Therapy Exception Request form prescription-drug-prior-authorization-request-form. If the drug is denied, you have the right to an external review.

If we deny a request for coverage of a drug not on the plan’s formulary, a non-formulary drug, you, your Authorized Representative or your doctor may request that the original exception request and subsequent denial of such request be reviewed by an independent review organization (IRO). You, your authorized representative or your doctor may submit a request for IRO review up to 180 calendar days following the non-formulary drug exception request denial by:

Calling toll-free at 1-855-298-4252
Mailing a written request to:
Attn: Prescription Claim Appeals MC 109 – CVS Caremark
P.O. Box 52084
Phoenix, AZ 85072-2084
Faxing a written request to: 1-866-442-1172
Completing the Member Grievance and Appeal form

You will be notified of the IRO’s decision within 72 hours for standard requests or 24 hours for expedited requests.

The IRO review process described above is in addition to your rights to file a grievance or appeal with Sharp Health Plan and to file a Grievance or request an independent medical review (IMR) with the California Department of Managed Health Care.

If your appeal involves a request for coverage of a non-formulary Drug (referred to as a non-formulary exception request), we will provide you with a decision within 72 hours. A request may be expedited if urgent, in which case we will provide you with a decision within 24 hours. A non-formulary exception request is considered urgent when a member is suffering from a health condition that may seriously jeopardize the member’s life, health, or ability to regain maximum function or when the member is undergoing a current course of treatment using the non-formulary drug.

Explanation of benefits (EOB)

Sharp Health Plan will mail the EOB’s on or before the 10th of every month. The EOB's include any claims processed and paid the previous month and any encounters or pharmacy claims included on the files received in the previous month.

Coordination of benefits

Coordination of Benefits (COB) is a process, regulated by law, which determines the financial responsibility for payment when a Member has coverage under more than one plan. The primary carrier pays up to its maximum liability and the secondary carrier considers the remaining balance for covered services up to, but not exceeding, the benefits that are available and the dentist's actual charge.

Determination of primary coverage is as follows:

For a Group Medical Insurance Qualified Health Plan: A Group Medical Insurance Qualified Health plan providing pediatric dental essential health benefits is the primary carrier for such covered services. This applies to plans provided on the California Health Benefit Marketplace and to plans provided outside such Marketplace.

For Dependent Children covered under Group Dental Plans: The determination of primary and secondary coverage for Dependent children covered by two parents' plans follows the birthday rule. The plan of the parent with the earlier birthday (month and day, not year) is the primary coverage. Different rules apply for the children of divorced or legally separated parents; contact the Member Services Department if you have any questions.