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.
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: firstname.lastname@example.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.
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.
If you are interested in becoming a SHPS provider or need more information about the credentialing process, browse the sections below.
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.
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.
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.
TTY: 711 (for the hearing and speech impaired)
Mon - Fri
8 am - 5 pm
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.
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.
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
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.
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.
The provider directories below are updated on a quarterly basis. Please contact your health plan for current listings of in-network providers and facilities.
- Scripps Coastal Medical Center (SCMC) Provider Directory (PDF, 3.2 MB) (Effective 11-01-2023)
- Scripps Clinic Medical Group (SCMG) Provider Directory (PDF, 3.2 MB) (Effective 11-01-2023)
- SHPS Ancillary Provider Directory (PDF, 1.1 MB) (Effective 11-01-2023)
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
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.
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, 520 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:
- Case management
- Credentialing and becoming a SHPS provider
- Eligibility verification
- Fraud, waste and abuse
- Grievance process (PDF, 120 KB)
- Language translation services
- Medical management
- Medical records documentation standards (PDF, 120 KB)
- Prior authorization
- Provider directories
- Quality management and improvement
- Scripps Care Link
- Timely access to care
- 2023 SHPS Compliance Plan (PDF, 510 KB)
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.
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.
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
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).