Providers

Provider resources

We offer the administrative support needed so you can focus on providing top-quality patient care

Committed to being your health care resource

You strive to provide superior health services in a caring environment and to make a positive, measurable difference in the health of individuals in the communities you serve. Scripps Health Plan Services (SHPS) — a management services organization (MSO) — shares that mission.

Care management

The Care Management Program uses a member/caregiver approach to promote availability of appropriate care and resources while maximizing the member’s quality of life and health care benefits. The assigned Case Manager works directly with the member and the family/caregiver(s) to develop an Individualized Care Plan (ICP) that is focused on increasing access to resources and services that support the member’s health needs. 


Complex Case Management (CCM) is provided to Members who have experienced a critical event or diagnosis that requires extensive use of resources and requires oversight to navigate the needed delivery of care and services. Case management becomes complex when the illness and/or conditions and complexity are severe and require an intense level of management beyond that of Case Management.


Did you know that anyone can make a referral to our Care Management Department for Scripps Coastal Medical Center and Scripps Clinic Managed Care patients? All requests will be reviewed for clinical appropriateness. Referrals can be made via:


• Epic: ambulatory order #210

• Email: shpsccmreferrals@scrippshealth.org

• Voicemail: 888-399-5678

• Fax: (858) 260-5834

• Care Management Referral Form (PDF, 58 KB)


Referrals must include the following details: patient’s medical record number (MRN), patients name and why you are referring the patient to the Case Management Department.

Claims

SHPS is dedicated to promoting an efficient and seamless claims process for all our providers. We will work closely with you and your staff to provide the timely and accurate support you need.


SHPS professional and institutional matrices for claims submissions assist providers in determining where to submit claims. Our matrices are updated regularly and provide general guidelines. The Claims Department is responsible for accurately and promptly processing claims for which SHPS is financially responsible.

Claims submission

Commercial and Medicare providers can submit claims electronically through one of our trusted clearinghouse partners: 



Please refer to the Trading Partner EDI Companion Guidelines (PDF, 440 KB) for assistance with submitting electronic claims.


Paper claims may be submitted to:


Scripps Health Plan Services

Attention: Claims

PO Box 2079

La Jolla, CA 92038


Corrected claims

Claims requiring corrections must be submitted with resubmission code 7 in field 22 on the CMS 1500 and field 4 on the UB-04. The original claim number is required.


Claims Payment

SHPS will pay claims at the lesser of its billed charges or at the negotiated rate and/or fee schedule whichever is less. SHPS will not be responsible for paying any amount that exceeds the billed charges

Commercial claims out-of-network fee schedule

Unless otherwise agreed by SHPS and a non-contracted individual health professional, SHPS may reimburse the non-contracted individual health professional who provides non-emergency services at a SHPS contracted facility the greater of the following:


  1. Average contracted rate; or
  2. 125 percent of the amount Medicare reimburses on a fee-for-service basis for the same or similar services in the general geographic region in which the services were rendered


The “average contracted rate” means the claims-volume weighted average of the contracted commercial rates that SHPS paid for the same or similar services in the geographic region in the applicable calendar year.


Claims for non-contracted providers for services provided at a non-contracted facility will be priced through MultiPlan.

Electronic fund transfers

SHPS is now able to send electronic fund transfers (EFT). If you would like to sign up for EFT, please fill out the EFT form (PDF, 220 KB) and return to us by fax or email. Please provide all information requested on the form and if you have any questions please email us at providerrelations@scrippshealth.org.


Remittance Advice (RA)

There are two ways to receive RAs:


1) Electronic Remittance via your clearinghouse, or


2) Scripps Care Link


If you already have access to Scripps Care Link, you can now access your RAs. If you would like to be set up with Scripps Care Link please return the appropriate forms for access.  Electronic remittance are provided through your clearinghouse so your trading partner information would be needed.

Institutional matrix for claims submissions

Medicare Advantage out-of-network fee schedule 

SHPS reimburses non-contracted care provider claims in accordance with the current established locality-specific Medicare physician fee schedule, diagnosis-related group (DRG), ambulatory payment classifications (APC) and other applicable pricing published in the Federal Register.


This physician payment schedule can be obtained via Noridian Healthcare Solutions. 

Professional matrix for claims submissions

Provider dispute resolution

Use our Provider Dispute Resolution (PDR) request (PDF, 410 KB) to submit a written notice challenging, appealing or requesting reconsideration of a claim or a bundled group of substantially similar multiple claims that are individually numbered.

Timeliness policies for commercial claims 

Contracted providers must submit commercial claims within 90 days of the date of service. Non-contracted providers must submit commercial claims within 180 days of the date of service.


SHPS will adjudicate complete claims within 60 calendar days of date of receipt and 30 calendar days for Employee Retirement Income Security Act of 1974 (ERISA) members. A complete claim is defined as a claim that may be processed without obtaining additional information from the provider of service or from the patient.

Timeliness policies for Medicare Advantage claims

Medicare Advantage claims must be submitted within 365 days from the date of service.


SHPS will adjudicate complete claims within 60 calendar days of date of receipt for contracted providers and 30 calendar days for non-contracted providers. A complete claim is defined as a claim that may be processed without obtaining additional information from the provider of service or from the patient.

Credentialing

If you are interested in becoming a SHPS provider or need more information about the credentialing process, browse the sections below.

Credentialing and recredentialing for contracted providers

Credentialing and recredentialing is required for all contracted providers, practitioners and allied health care professionals (for example, physician assistants and nurse practitioners) and health delivery organizations providing services to SHPS members. The Quality Improvement staff, as part of the credentialing and recredentialing process, may perform site visits and medical record reviews. Providers will be contacted in advance if a site visit or audit is needed.

How to become a SHPS provider

Download How to Become a SHPS Provider (PDF, 200 KB) to complete and submit the questionnaire and start the credentialing process.


After receiving the practitioner’s completed questionnaire, SHPS will initiate the credentialing process and will complete the primary source verification based on National Committee for Quality Assurance (NCQA) standards and other pertinent information supplied or collected during the application process.


After medical staff office review, credentialing information is presented to the Credentialing Review Panel for review and approval. The Credentialing Review Panel meets quarterly. Providers are notified in writing of the Credentialing Review Panel’s decision. Final credentialing approval is granted by the SHPS Board of Directors, which also meets on a quarterly basis.

Provider rights and correction of erroneous information

Scripps Health Plan Services (SHPS) protects its members by assuring that the care they receive is of the highest quality. One way in which SHPS accomplishes this is by credentialing our providers in accordance with state and federal regulatory requirements and accreditation standards. Your provider responsibility includes full disclosure of all issues and timely submission of all credentialing and re-credentialing information.


As a provider, you have the right to:


  • Nondiscrimination during the credentialing process
  • Confidentiality of all information submitted during the credentialing process
  • Be notified of information obtained during the credentialing process that varies substantially from what is submitted by you
  • Review information submitted to support your credentialing application, with the exception of references, recommendations and peer-review protected information
  • Be informed of the status of your application upon request, you can email the Credentialing * Department at SHPSCRED@scrippshealth.org
  • Receive notification of the credentialing decision within 60 days of the SHPS’s decision
  • Receive notification of your rights as a provider to appeal an adverse decision made by SHPS
  • Be informed of the above rights


Please review your Provider Manual or call your Provider Relations Specialist if you have any questions regarding the above.


Provider’s Right to Notification and Correction of Erroneous Information: 


SHPS will notify you, the Provider, in writing, in the event that SHPS receives conflicting information. Areas where variation from information provided may occur include, but are not limited to, actions on a license; malpractice claims history or board certification. SHPS is not required to reveal the source of information that was not obtained to meet verification requirements. A notification to you will identify the information in question and the apparent conflict. You have the right to correct erroneous information within thirty (30) calendar days of receiving notification from SHPS by submitting a written response to:


Scripps Health Plan Services, Inc.  

Attention: Credentialing 4S-300

10790 Rancho Bernardo Road

San Diego, California 92127


You are required explain any discrepancy and include any proof that may be available in order to support your request. Please be advised that any failure to honestly, fully and completely provide information can be used to recommend and adverse credentialing decision, even if you correct your response. If you do not respond within thirty (30) calendar days of notification, your application will be considered withdrawn and processing will be discontinued. Upon receipt of any response from you, SHPS may re-verify the primary source information in dispute. If the primary source information has changed, correction will be made immediately to the credentials file. You will be notified in writing of any correction has been made to the credentials file. If the primary source information remains inconsistent, the Credentialing Department will notify you. 

Eligibility verification

Providers are responsible for verifying every member’s eligibility with the health plan prior to rendering authorized services, unless the services are emergent. All members should present their health plan identification card each time services are requested.

Language translation services

Providers may request interpreters for members whose primary language is not English by calling SHPS customer service. SHPS will coordinate with the patient's full-service health plan.


888-680-2273

TTY: 711 (for the hearing and speech impaired)


Hours

Mon - Fri

8 am - 5 pm


Translate our website

Open our Accessibility Menu and click “English (USA)” to translate our entire site into a different language.

Medical management

Changes occurring in health care require health systems and physicians to find innovative ways to work together to deliver coordinated care to both improve quality and contain costs. We are dedicated to maintaining the highest quality and efficiency of medical management via comprehensive collaboration with our providers. SHPS providers share our vision of patient-centered care. Together we will enhance inclusive models of care delivery that will allow us to meet the needs of patients across the San Diego region.


We maintain a wide-ranging, coordinated process, which promotes and monitors the effective use of health care resources within SHPS’ health care delivery system. The Medical Management Committee’s (MMC) responsibilities include ongoing evaluation and improvement of the Utilization Management (UM) Program. MMC is accountable for monitoring clinical practices, evaluation of provider utilization, as well as tracking and trending of provider appeals and grievance determinations. Other activities within the scope of the UM program include the following:


  • Complex case management
  • Concurrent and retrospective review
  • Continuity of care 
  • Discharge planning
  • Out-of-area coordination of care and repatriation
  • New medical technology review and determination
  • Post-stabilization care
  • Prior authorization
  • Referral management
  • UM key service and administrative performance indicators


Contracted providers may request copies of any guidelines or review criteria used by SHPS in the course of UM activities by calling SHPS customer service.

Utilization management statement

SHPS utilization management decision making is based on appropriateness of care, service and the existence of coverage. 


SHPS does not:


  • Compensate practitioners or individuals for denials
  • Offer incentives to encourage denials
  • Encourage decisions that result in under utilization


SHPS ensures independence and impartiality in making referral decisions that will not influence hiring, compensation, termination, promotion and any other similar matters.


Members may request a copy of the criteria used in making referral decisions. To obtain a copy of the actual benefit provision, guideline, protocol or other similar criterion on which the decision was based, upon request and free of charge, by calling SHPS customer service:


888-680-2273

TTY: 711 (for the hearing and speech impaired)

Mon – Fri

8 am – 5 pm

Prior authorization

Do you need prior authorization or a referral for your patient’s care? We’re here to help.


Referrals and authorizations

Scripps Health Plan Services maintains a list of services that require prior authorization. Providers should inform the member’s primary care physician of the need for further referral, treatment, or consultation to determine which services must have prior authorization and the process by which services are reviewed for authorization.


For questions about services requiring prior authorization:


  • Review the Scripps Health Plan Services Prior Authorization Guide (PDF, 180 KB) or call Scripps Health Plan Services customer service at 888-680-2273. This information pertains to contracted providers within the member’s primary medical group.  
  • Services to be rendered by non-contracted providers outside of the member’s primary medical group always require prior authorization unless the services is medically necessary and provided on an urgent or emergent basis.


Prior authorization is NOT required for:


  • Basic prenatal care
  • Emergency services
  • Family planning services
  • Human immunodeficiency virus (HIV) testing
  • Preventive care, like immunizations and annual physicals
  • Sexually transmitted disease (STD) testing and treatment

Authorization request form

Submit Authorization Requests for SCMG or SCMC patients who need medical services through Scripps Care Link or use the Authorization Request Form (PDF, 610 KB).

Authorization status

Providers will receive a written authorization letter that will specify the extent of the services authorized. Providers may not exceed those authorization limits without an additional authorization, except in the case of a medical emergency. Visit Scripps Care Link to check status.

Authorization submission process

In compliance with the Department of Managed Health Care (DMHC) Commercial and Center of Medicare & Medicaid Services Senior turn-around-time standards for members, determinations for expedited and routine requests are not to exceed the mandated timeframes.  


Prior authorization criteria and guidelines

What is the turnaround time once a prior authorization has been submitted?


Commercial:


  • Routine: Within 5 business days
  • Expedited: Within 72 hours
  • Extension: Within 45 calendar days when it is in the member’s best interest to obtain additional information that would support the request (a member or provider may request this so they can provide the needed information)
  • Pharmacy: Routine within 72 hours and Expedited within 24 hours  


Senior:


  • Standard: Within 14 calendar days
  • Expedited: Within 72 hours
  • Extension: Within 14 additional calendar days when it is in the member’s best interest to obtain additional information that would support the request (a member or provider may request this so they can provide the needed information)
  • Pharmacy: Standard 72 hours and Expedited 24 hours  


Please refer to your provider manual and the forms under the authorization submission process for complete turnaround times by line of business.


In making referral and authorization decisions, SHPS utilizes clinical guidelines and criteria provided by Centers for Medicare and Medicaid Services (CMS) Criteria using both National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), your health plan criteria, Hayes and MCG (nationally recognized guidelines which are reviewed and updated at least annually).


The Health Care Service Plans (HCSPs) will develop the clinical guidelines based on professionally recognized standards of practice and review all criteria annually.

Post-stabilization care

Prior authorization is required for post-stabilization services. Neither Scripps Health Plan Services nor the member can or will be held financially responsible for any unauthorized care provided by a facility.


For emergent medical admissions or transfers, call Scripps Centralized Transfer Center at 858-678-6205.

Provider directories and updates

The provider directories below are updated on a quarterly basis. Please contact your health plan for current listings of in-network providers and facilities. 



Some hospitals and other providers do not provide one or more of the following services that may be covered under a plan contract:


  • Family planning
  • Contraceptive services, including emergency contraception
  • Sterilization, including tubal ligation at the time of labor and delivery
  • Infertility treatments
  • Abortion


Directory updates

To ensure patients have access to accurate and complete provider information in our directories, please report all data errors or practice changes using the Provider Demographic Update (PDF, 200 KB) form.

Provider resources, forms and information

It is our priority at SHPS to assist your practice in adhering to federal, state, and health plan requirements and regulations.


Contracted professionals, facilities and ancillary providers can use our Provider Operations Manual (PDF, 860 KB) to find information about medical management, claims, reimbursement and compliance.


SHPS Provider Newsletter contains information on managed care, utilization and case management, claims and provider dispute requests, payor and plan updates, compliance and a variety of other resources.


Through this site, SHPS providers can find information about the following:


Quality management and improvement

The purpose of the SHPS Quality Management (QM) Program is to maintain a comprehensive, coordinated process that continually evaluates, monitors and improves the quality of clinical care and service provided to members within the SHPS health care delivery system. The SHPS QM Program incorporates review and evaluation of all aspects of the health care delivery system.

Potential Quality Issue (PQI) 

A Potential Quality Issue (PQI) is any suspected provider quality of care or service issue that has the potential to impact the level of care being provided to the enrollee/patient. Providers may include independent physicians, medical groups, hospitals, nurses, ancillary providers, and their staff as well as health plan staff. The PQI Referral Form (PDF, 270 KB) is to be used to report any potential or suspected deviation from the standard of care that cannot be determined to be justified without additional review. A PQI can be occur at any point during patient care, including but not limited to:


  • Access and Availability
  • Assessment/Treatment/Diagnosis
  • Cleanliness
  • Communication/Conduct
  • Continuity of Care
  • Language Assistance Program (LAP)
  • Pharmacy
  • Privacy/HIPAA
  • Safety
  • Utilization Management

 

The PQI FAQ (PDF, 170 KB) provides additional information regarding proper identification of a PQI, as well as a summary of the steps taken by the Quality Management Team during their investigation.

Scripps Care Link provider portal

We encourage all providers to use Scripps Care Link. A provider portal, it allows real-time web access to patient information, so you can view membership data and communicate with SHPS to provide quality patient care.

Benefits of Scripps Care Link

In the Scripps Care Link portal, you can:


  • Check claim status
  • Submit referrals
  • Check referral status
  • Request modifications or extensions to existing authorizations
  • Verify member eligibility
  • Send and receive secure messages via ‘In Basket’ feature

Request access to Scripps Care Link

Complete the application 

If you are a contracted provider and wish to apply for access to the provider portal, Scripps Care Link:


  1. Download the Scripps Care Link Access Request Form and Attestation/Confidentiality Form (PDF, 330 KB)
  2. Fill out the application
  3. Read and sign the Confidentiality and NDA


The NDA includes information about Protecting Health Information (PHI), Personal Financial Information (PFT) and other sensitive and proprietary information accessible via Scripps Care Link and protected by Scripps’ policies and the law. As a contractor, employee, medical staff member, volunteer or other third party with access to Scripps’ information, the NDA must be understood and signed.  


Sign the administrator agreement

If applicable to your role, sign and complete the Scripps Care Link Site Administrator Agreement (PDF, 130 KB) to ensure compliance and acknowledgment of your responsibilities as a Scripps Care Link affiliate site administrator.


Applications should be emailed to scrippscarelink@scrippshealth.org or faxed to 858-260-5851.

Timely access to care

California has set standards for health plans and providers to ensure members have access to health care in a timely manner. Learn more about those standards in the Timely Access to Care Notice (PDF, 170 KB).