Authorizations

Authorization Forms for members assigned to SFHP for Utilization Management

Please note in addition to completing the UM Prior Authorization Request Form you must also fill out a NPI Registration form and a W-9 form.

Pharmacy Forms for all SFHP members

Authorizations are based on medical necessity and covered services. Authorizations are contingent upon a member’s eligibility and available benefits. Authorizations are not a guarantee of paymentThe provider is responsible for verifying a member’s eligibility on the dates of service.

Please verify eligibility by using one of the following methods for each date of service:

Web: San Francisco Health Plan

Interactive Voice Response: 1(415) 547-7810

SFHP Member Services: 1(800) 288-5555

Obtaining Prior Authorization for Services

Please fax all authorization requests according to the member’s medical group listed in the directory below. Or you can login to the Provider Portal to submit authorization requests as well. Fill out the UM Prior Authorization Request Form and make sure to include the member’s name, date of birth, CPT/HCPCS codes (include quantity), diagnosis codes, and place of service. In addition, please provide clinical notes to support your request; such as recent notes on the member’s health history and progress, physical exams, prescriptions, and the medical reasons for the requested service. If the requested service will be rendered outside of the member’s assigned medical group, please state why it cannot be performed within the member’s network.

Prior authorization of services is required for all procedures, out-of-network referrals (e.g. a CHN member consulting with a UCSF specialist) and planned inpatient admissions. Referrals for office visits or office consultations within a member’s medical group do NOT require prior authorization. Please reference the Services Requiring Prior Authorization document for more information.

SFHP’s Utilization Management Department processes authorization requests for members assigned to either the Community Health Network (CHN) or UCSF medical group. SFHP also processes authorization requests for any Brown & Toland Physicians or Hill Physicians members that request services outside of San Francisco. If your patient is assigned to Brown & Toland Physicians, North East Medical Services, Hill Physicians, Chinese Community Health Care Association, or Kaiser Permanente San Francisco, please refer to the contact information listed below to request services from the delegated group directly. If you are unsure of your patient’s assigned medical group, you can either login to the Provider Portal or call SFHP at 1(415) 547-7818 ext 7101.

Medical GroupPhoneFax
Brown & Toland Physicians 1(415) 972-6002 1(415) 972-4248 (Outpatient Services)
1(415) 972-4239 (Inpatient Admissions)
Community Health Network (CHN)
– SFHN Clinics
– SFCCC Clinics
1(415) 547-7818 ext 7080
1(415) 615-4525 (Inpatient 24/7)
1(415) 357-1292 (Outpatient Services)
1(415) 547-7822 (Inpatient Admissions)
UCSF 1(415) 547-7818 ext 7080
1(415) 615-4525 (Inpatient 24/7)
1(415) 357-1292 (Outpatient Services)
1(415) 547-7822 (Inpatient Admissions)
Chinese Community
Health Care Association (CCHCA)
1(888) 467-4390 option 3 (Outpatient Services)
1(888) 467-4390 option 3 (Inpatient Admissions)
1(888) 467-6802 (Outpatient Services)
1(888) 467-6802 (Inpatient Admissions)
Kaiser Permanente San Francisco 1(415) 833-2801 1(415) 833-2657
North East Medical Services (NEMS) 1(415) 352-5045 1(415) 398-2895
Hill Physicians 1(800) 445-5747 1(925) 820-4311 (Outpatient Services)
1(925) 362-6577 (Inpatient Admissions)

Timeframes for Medical Authorization

As of 11/12/2013, pre-authorizations will be valid for 365 days. However, the appropriate number of units needs to be requested and reviewed every 90 days. Please mention the original authorization’s reference number when sending in a modification request. To check the status of an authorization request you submitted, login to the Provider Portal.Timeframes for Medical Authorization

Routine – SFHP has 5 business days to respond to a Routine Pre-Authorization request upon receipt of all necessary information.

Expedited – For requests where following the standard, routine timeframe could seriously jeopardize the member’s life or health, or ability to attain, maintain or regain maximum function, providers should clearly mark the request URGENT and the request will be processed expeditiously. SFHP has 72 hours to respond to an Expedited Pre-Authorization upon receipt of all necessary information.

Please note, a request for an elective (non-urgent) surgery or treatment submitted urgently due to imminent date of service is NOT considered to be urgent. Authorization requests submitted for these services will be processed as Routine. Only requests that are considered medically urgent will be processed expeditiously.

Inpatient Admissions – are processed via Expedited Concurrent Review. For more information regarding requests for post-stabilization care click here.

Retrospective – Any authorization request that is submitted after initiation and completion of services will be processed according to a retrospective timeframe. Providers should clearly mark the request RETRO and state the exact Date of Service(s). A retrospective request must be received within 30 calendar days of the first date of service. If the service is ongoing, please state this clearly in the comments section. SFHP has 30 calendar days to respond to a retrospective request upon receipt of all necessary information.

Medical Necessity Criteria

SFHP determines medical necessity using Medi-Cal, InterQual, and other nationally recognized evidence-based criteria. In addition, we develop our own criteria for specific situations. The following criteria are updated and approved by the SFHP Quality Improvement Committee. If you have any questions, please call 1(415) 547-7818 ext 7080.

Ancillary Providers (DME, Home Health, Transportation, etc.)

If the requested service involves an ancillary provider, please contact the ancillary provider directly and they will submit the authorization request for you. Examples include requests for durable medical equipment, medical supplies, dialysis, home health, home infusion, orthotics, prosthetics, and transportation. Click here to view a list of our contracted Ancillary Providers.

Emergency transportation does NOT require authorization from SFHP. In addition, non-emergent transportation from facility to  facility or facility to a residence does NOT require an authorization. However, SFHP requires authorization for non-emergent transportation from a residence to a facility and any non-emergent transportation to/from a Dialysis Center. SFHP will accept retrospective authorization requests (requests submitted after the service was rendered) for transportation services.

Approved authorizations will be valid for 365 days though the appropriate number of units needs to be requested and reviewed every 90 days. After the first 90 days have passed, please submit a renewal request to add another 90 days of units if needed. Please mention the original authorization’s reference number when sending in a modification or renewal request.

Inpatient Admissions

Authorization is NOT required for observation or emergency pre-stabilization services delivered in an emergency department or ambulance setting.

For information regarding authorization requests for post-stabilization care click here:

Mental Health Services

As of January 1, 2014, San Francisco Health Plan will provide non-specialty mental health benefits as part of Medi-Cal managed care. Members can receive non-specialty mental health care at either their assigned clinic/medical group (for clinics that have integrated behavioral health) or off-site with Beacon Health Strategies. Non-Specialty Mental Health Services are defined as services for members with mental health diagnoses and mild to moderate functional impairment. The following non-specialty services are offered:

  1. Individual and group mental health evaluation and treatment (Psychotherapy)
  2. Psychological testing when clinically indicated to evaluate a mental health condition
  3. Outpatient services for the purposes of monitoring drug therapy
  4. Outpatient laboratory, drugs, supplies, and supplements
  5. Psychiatric consultation

Behavioral health services do not require prior authorization from SFHP; please contact either the member’s assigned clinic or Beacon Health Strategies directly to request these services. All referrals to SFCBHS must be made by the member’s PCP.

SFHP members with mental health diagnoses and severe functional impairment will continue to receive specialty services at SFCBHS. Specialty mental health is still carved-out and is billed directly to the state.

SFCBHS Access Center
1380 Howard Street, 1st Floor
San Francisco, CA 94103
Phone: 1(415) 255-3737
Fax: 1(415) 255-3629

Pharmacy Authorizations

If the medication needs to be picked up in a pharmacy, please complete the Pharmacy Authorization Request Form.

If the medication will be administered in a doctor’s office or other facility, please fill out the UM Prior Authorization Request Form. In this case, it is the provider’s responsibility to obtain the medication.

Healthy SF

SFHP’s UM Department does not process authorization requests for participants in Healthy SF. Each HSF Medical Home does its own UM. To find where your patient is assigned and to get that specific Med Home’s UM contact info, please contact Healthy SF’s Med Home Services.

Phone: 415-615-4555, Option 5
Email: info@healthysanfrancisco.org
Hours: Monday-Friday 8:30am-5:30pm
Website: Healthy San Francisco