Inpatient Admissions

Authorizations are based on medical necessity and covered services. Authorizations are contingent upon a member’s eligibility and are not a guarantee of payment. The 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:

1. Interactive Voice Response: 1(415) 547-7810
2. SFHP Member Services: 1(800) 288-5555

SFHP’s Utilization Management Department processes authorization requests for SFN, CLN, UCSF, or SDN members. In addition, SFHP also processes 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, All American Medical Group, 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.

Inpatient Admissions

For members assigned to the UCSF medical group, San Francisco Health Network (SFN), Community Clinic Network (CLN), or SFHP Direct Network (SDN), please submit an authorization request for inpatient admission within 24 hours or by 5:00pm the next business day. To submit an authorization request for inpatient admissions, please fax a facesheet to 1(415) 547-7822. Authorization requests for Inpatient Admissions are processed via Expedited Concurrent Review. If you have additional questions please contact SFHP UM Department at 1(415) 547-7818 ext 7080.

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

Administrative Days

Administrative days are an SFHP covered benefit. The types of administrative days to be reviewed are:

• Administrative Days Level 1: A lower administrative days level of service rendered to a patient in an acute care hospital awaiting placement in a Nursing Facility Level A (NF-A) or Nursing Facility Level B (NF-B).
• Administrative Days Level 2: For services rendered to patients awaiting placement in a sub-acute Nursing Facility. Per DHCS guidelines, Level 2 administrative days are allowed to private hospitals. Publicly funded hospitals are not allowed Level 2 administrative day authorizations.

Hospital must request administrative days while the member is currently admitted to the hospital and supply evidence of 10 Skilled Nursing Facility (SNF) referrals daily, with the exception of weekends and holidays. SFHP performs medical necessity review using MCG Recovery Facility Care guidelines.

How Can I Tell if My Patient Is a Member of SFHP?

If the hospital can identify the patient, they should be able to determine if the patient has Medi-Cal, and if their health plan is SFHP. The hospital can check the patient’s wallet for a SFHP Member ID Card, consult with the family, check the Medi-Cal Website, or access our Provider Portal. You can also call SFHP at 1(415) 547-7810.

How Can I Tell Which Medical Group My Patient Is Assigned To?

Providers can verify a member’s eligibility and assigned medical group by either logging into the Provider Portal or calling SFHP at 1(415) 547-7810.

Pre-Authorizations

To request prior authorization of services, please 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, prescriptions, physical exams, 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 CLN 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.

For more information regarding pre-authorization requests for planned admissions or outpatient services, please click here.

Ancillary Providers (DME, Home Health, Transportation) for Discharge Planning

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. Search our Provider Directory to find contracted providers, including providers to refer for DME, audiology, and other ancillary services.

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.

For more information regarding pre-authorization requests for ancillary providers, please click here.