Understanding Prior Authorization and Utilization Management (UM)
We want you to get the care you need when you need it. Sometimes your doctor needs to ask San Francisco Health Plan (SFHP) for approval before you can get certain care. This is called prior authorization. Prior authorization can apply to SFHP, SFHP Care Plus (HMO D-SNP), and Healthy Workers HMO members.
What Is Prior Authorization?
Prior authorization makes sure the care you get is medically needed. Prior authorization means your provider asks SFHP to approve certain services before you get them.
These may include:
- Some health tests and procedures
- Hospital stays
- Specialty care
- Medical equipment
- Certain medications given by your doctor
- Care outside the SFHP provider network
- Long-term care or special equipment
To find a list of services that need prior authorization, visit our code look-up tool.
What Is Utilization Management (UM)?
Utilization Management is how SFHP reviews requests for care and services. Licensed nurses and doctors will check requests to make sure the care is:
- Medically needed
- Right for your condition
- Covered under your plan benefits
We make decisions based on medical needs and your coverage rules. SFHP does not give monetary rewards to anyone for denying a request for coverage. There are no financial incentives for UM staff or separate consultants to make a decision that leads to coverage denial.
How UM Decisions Are Made
To make a UM decision, our clinical reviewers use:
- National health guidelines
- Evidence-based clinical guidelines
- Professional standards of care
- Your health information
- Your benefit coverage
If needed, we may ask your provider for more details about your request.
How to View Clinical Guidelines
Medicare and Medi-Cal guidelines are publicly available. You can also find SFHP’s internal coverage guidelines and policies, including MCG care guidelines, online: Medical Criteria.
MCG guidelines are independent care guidelines that we use to make coverage decisions. To view them, follow these steps:
Step 1: Click here to find the MCG care guidelines. Read the disclaimer and accept the terms and conditions.
Step 2: Complete the User Information form.
Step 3: Complete the verification process to continue.
Step 4: Click on the arrow icon to expand the list of guidelines in the content group.
Step 5: Click on the guideline you want to see.
What Guidelines Were Used for My Review?
You can ask us for the exact guidelines we used to review your request. We will provide it at no cost by email or mail.
To ask for the guidelines used for your review, call Customer Service.
- For SFHP Medi-Cal and Healthy Workers HMO members: Call SFHP Customer Service at 1(415) 547-7800, 1(800) 288-5555 (toll-free), or 711 (TTY), Monday–Friday, 8:00am–5:00pm.
- For SFHP Care Plus (HMO D-SNP) members: Call SFHP Care Plus Customer Service at 1(415) 539-2273, 1(833) 530-7327 (toll-free), or 711 (TTY), 8:00am–8:00pm.
SFHP Care Plus Customer Service is open seven days a week from October–March, closed Saturdays and Sundays from April–September.
When Will I Get a Decision About My Care?
We review requests as quickly as possible based on medical urgency. We follow state and federal rules for reviewing requests:
- We review urgent requests within 72 hours or faster when health could be at risk
- We review standard requests within 7 calendar days
You and your provider will get a written notice of our decision.
What Happens If My Care Is Not Approved?
If a request is denied, you will get a letter that tells you:
- The reason for the decision
- The clinical guideline we used
- How to ask for an appeal
- How to ask for a fast appeal if needed
- How to ask for help
You have the right to appeal decisions. Customer Service can help you understand your appeal options.
Need Help? SFHP is Here for You
Not sure whether you need prior authorization or want to file an appeal? You can ask your doctor or call Customer Service.
- For SFHP Medi-Cal and Healthy Workers HMO members: Call SFHP Customer Service at 1(415) 547-7800, 1(800) 288-5555 (toll-free), or 711 (TTY), Monday–Friday, 8:00am–5:00pm.
- For SFHP Care Plus (HMO D-SNP) members: Call SFHP Care Plus Customer Service at 1(415) 539-2273, 1(833) 530-7327 (toll-free), or 711 (TTY), 8:00am–8:00pm.
SFHP Care Plus Customer Service is open seven days a week from October–March, closed Saturdays and Sundays from April–September.
With SFHP, you can get help in your language at no cost. If you need language support to talk about UM or other questions, you have the right to get an interpreter. After business hours, staff can receive secure voicemail, fax, and email. We will answer messages the next business day. If we get a message after midnight Monday through Friday, we will respond the same business day.
Prior Authorization Program Results
We review how our prior authorization process works to make sure it is fair and timely.
We track:
- How many requests we get
- How long it takes us to make a decision
- How often we approve or deny requests
To see a summary of our findings, visit Prior Authorization Program Metrics Report. We update these reports each year.