SFHP Medical Criteria

San Francisco Health Plan (SFHP) reviews authorization requests to ensure members receive medically necessary, appropriate, and covered services.

We review each request against established clinical criteria and guidelines used across the health care industry.

The information on medical criteria used for a member’s authorization decision is available below at no cost to members and providers.

Criteria Hierarchy

We follow nationally recognized, evidence-based criteria. When making medical necessity decisions, SFHP uses the following hierarchy:

1. Federal and State Requirements
Examples include:

• Medicare NCD policies
• Medicare LCD policies
• Code of Federal Regulations (CFR)
• California Code of Regulations (CCR), Title 22 & Title 28
• California Welfare and Institutions Code
• DHCS Medi-Cal Provider Manuals
• DHCS All Plan Letters
• DMHC All Plan Letters

2. Evidence-Based Clinical Guidelines

• MCG Health Care Guidelines (See section below for instructions on how to access guidelines)
• InterQual (Behavioral Health Only. See Carelon Medical Criteria page for instructions on how to access guidelines.)
• WPATH Standards of Care
• NCCN Guidelines
• ASAM Criteria
• ASRM Practice Guidance
• UpToDate Clinical Summaries

3. SFHP Internal Criteria

• EPSDT Private Duty Nursing Criteria (Medi-Cal Only)

If criteria are still not available, SFHP uses an Independent Review Organization (IRO) such as Medical Review Institute of America (MRIoA), which provides specialty physician review.

SFHP partners with delegated entities to administer Behavioral Health, Dental, and Chiropractic services.

• To view the medical criteria used for Behavioral Health services click here
• To view the medical criteria used for Dental services click here
• To view the medical criteria used for Chiropractic services click here

How to Access MCG Care Guidelines

MCG does not allow SFHP to distribute guidelines directly, but they provide a viewing portal for members and providers.

Steps to Access:

1. Click here.
2. Read the disclaimer and accept the terms.
3. Complete the User Information Form.
4. Complete the verification process.
5. Expand the categories to view guidelines.
6. Select the guideline you want to view.
   (Note: You can view but not print MCG content)

Gender Affirming Care

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:

• WPATH Standards of Care 8
• DHCS Transgender and Gender Diverse Services Manual
• DHCS All Plan Letter 20-018 Ensuring Access to Transgender Services
• California Code, Health and Safety Code – HSC § 1374.551 Fertility Preservation (for Healthy Workers only)

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:

• Title 22, California Code of Regulations (CCR) Sections 51118, 51120, 51120.5, 51121, 51124, 51124.5, and 51124.6, and the criteria for admission set forth in Sections 51335, 51118, 51120, 51335.5, 51334, 51335.6, and referenced sections of 51003 (e)
• Welfare and Institutions Code (W&I) section 14132.25
• DHCS Medi-Cal Manual of Criteria