Authorization Forms for members assigned to SFHP for Utilization Management

Faxed requests must be submitted using SFHP’s current Prior Authorization request forms with all required information typed in; handwritten and incorrect request forms will not be accepted.

• Services Requiring Prior Authorization
• Code Lookup Tool
• UM Prior Authorization Request Form
• LTC Pre-Authorization form
• Provider Portal

If you are a new provider to San Francisco Health Plan, 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.

Non-Emergent Medical Transportation (NEMT) Combination Physician Certification and Prior Authorization Form

All fields must be completed:

• Function Limitation Justification
• ICD-10 Diagnosis Code
• Start date and end date (may not exceed 1 year)
• Mode of Transportation
• Name of Prescribing Provider
• Prescribing Provider Signature (electronically signed, handwritten, or stamped with official prescriber’s stamp only)
• Date signed by Prescribing Provider (order is valid for 1 year from signature date)

Altered NEMT PA forms (cross out, white out, etc.), handwritten (except for provider’s signature), incomplete, or incorrect request forms will not be accepted.

Obtaining Prior Authorization for Services

Please fax all authorization requests according to the member’s medical group/network 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.

For Non-Emergent Medical Transportation (NEMT) requests please use the Non-Emergent Medical Transportation (NEMT) Combination Physician Certification and Prior Authorization Form instead of the Prior Authorization Request Form. Make sure to fill out the form completely, all the information is needed to help ensure timely services for the member.

Prior authorization of services is required for all procedures, out-of-network referrals (e.g. a CLN or SFN 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. To open the Code Lookup tool, click here.

SFHP’s Utilization Management Department processes authorization requests for members assigned to either the Community Clinic Network (CLN), San Francisco Health Network (SFN), UCSF medical group, or SFHP Direct Network (SDN). SFHP also processes authorization requests for any Brown & Toland Physicians or Hill Physicians members that request services outside of San Francisco. Any requests for experimental/investigational services will require medical review by SFHP. 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.

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 submitted after initiation and completion of services will only be considered under the following conditions:

• Member receives retrospective eligibility.
• Certification of the Medi-Cal beneficiary’s eligibility by the county welfare department was delayed.
• Member does not identify himself/herself to the provider as a SFHP member by deliberate concealment, or because of physical or mental incapacity.
• Non-emergency medical transportation.
• Professional fees for radiology and pathology, received retrospectively, and connected with an approved service
• Beneficiary is transitioning into Medi-Cal Managed Care from Medi-Cal FFS and is requesting continuity of care. Provided that these services have occurred after the member’s enrollment into SFHP and that SFHP has the ability to demonstrate that there was an existing relationship between the member and provider prior to the member’s enrollment into SFHP.
• DME and Medical Supplies to prevent a delay in a hospital discharge.
• Supplies or services provided during an office visit that was either already authorized or did not require authorization.

Providers should clearly mark the request RETRO and state the exact Date of Service(s). If the service is ongoing, please submit a separate request for the ongoing Date of Service(s). Submissions with a combined retro and ongoing Date of Service(s) will not be accepted. Blood Draws for lab work are not considered to be retrospective requests. Please put the blood draw date in the justification section.

Requests meeting the above conditions must be submitted no later than 30 calendar days after the date of service and are subject to the same review criteria for medical necessity. SFHP has 30 calendar days to respond to a retrospective request upon receipt of all necessary information. Authorization requests received later than 30 calendar days after the date of service are denied.

Medical Necessity Criteria

SFHP determines medical necessity using Medi-Cal, MCG, and other nationally recognized evidence-based criteria. In addition, we develop our own criteria for specific situations. SFHP’s medical criteria can be viewed here. 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. 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.

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.

When submitting a modification request, please provide the changes/updates you would like in the “justification” section of the request form. Changes could be form of adding/removing services, changing providers, codes, units, etc.). Please use any reference authorization number if possible.

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 Carelon Behavioral Health. 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 Carelon Behavioral Health 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

Medications for Medi-Cal Members to pick up in a pharmacy are covered by Medi-Cal Rx beginning in 2022.  Please visit this page for details on the transition.

If the medication for a Healthy Workers HMO member 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.

Pharmacy Forms for all SFHP members

• Medi-Cal Rx Pharmacy Benefit for Medi-Cal Members 
• Pharmacy Page
• General Pharmacy Prior Authorization Request Form for Healthy Workers HMO
• Formulary Modification Request Form for Healthy Workers HMO

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 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:

Web: San Francisco Health Plan

Interactive Voice Response: 1(415) 547-7810

SFHP Member Services: 1(800) 288-5555

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