Dear SFHP Members: Congress was unable to reach an agreement on funding for Fiscal Year 2026, and the federal government was shut down on October 1, 2025. While we do not know how long the shutdown will last, SFHP will continue its operations as normal. You can still access the care you need. We are committed to ensuring your access to care is not interrupted. If you encounter any issues, please contact SFHP Customer Service at 1(415) 547 7800 or toll-free 1(800) 288 5555 (TTY users can dial 711). We’re open Monday through Friday, from 8:00am to 5:00pm.

1(415) 547-7800 Contact Us

SFHP Medical Criteria

SFHP uses external criteria MCG care guidelines, State/Federal (Medi-Cal/CMS), and when available and, in limited circumstances, internally developed and approved criteria (available below). The public, including providers and members, may obtain the relevant UM criteria for specific medical procedures or conditions on request at no cost.

UM Criteria for EPSDT Private Duty Nursing

Gender Affirming Care

As of 4/1/25, medical necessity criteria and guidelines for gender affirming care authorizations are accessed directly from World Professional Association for Transgender Health’s (WPATH) Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, Department of Health Care Services (DHCS) guides and California Health and Safety Code regulations.

Resources:

Long-Term Care Criteria

Decisions regarding the appropriate level of care are based on the definitions set forth in California regulations and DHCS Medi-Cal Manual of Criteria.

These guidelines are used to determine the medical necessity for continued placement in a long-term care facility. If care can be delivered at a lower acuity level, an alternative setting will be approved/ recommended. Classification categories include the following:

  • Subacute Care: The member requires subacute care, which is more intense than skilled nursing care but less intense than acute hospitalization. Members at this level of care either can be short term, where there is potential for the member eventually being transferred to a lower level of care; or long term, when there is no potential for improvement in their medical condition. Treatment Authorization Requests (TARs) for these members are authorized for time intervals based on the characteristics of the member’s medical condition.
  • Short Term Care: The member may need a short term stay for a skilled nursing care need or short term rehab services and expected to return to his/her previous living arrangement or alternate level of care.
  • Long Term Care: When a member is admitted for custodial care, the TAR submission may be approved for up to a twelve (12) month period. Member’s condition will be re-evaluated at six (6) -twelve (12) month increments, depending on the initial authorization period and plan of care.

Resources:

×

Cookies Policy

We use cookies and other tools to make our website easier to use.