Before providing treatment or prescribing medication for an HPSM member, you may need to submit a Prior Authorization Request Form to ensure that it is covered. HPSM expects providers to obtain authorization for all services requiring prior authorization before they provide the service. Exceptions are made for urgent and emergency services.
Please make sure your form meets the following requirements – failure to do so will result in a rejected request:
- Use the current Prior Authorization Request Form (version 3.2 September 2020)
- Use the fillable form (typed, not hand-written)
- Only select “Urgent” if it’s truly an urgent matter. Most requests will be “Routine” requests
- Do not check the “LTC” box unless you are truly a long-term care provider or facility
For authorization requests submitted prior to the date of service, expect a response from HPSM:
- 72 hours for urgent (a delay in care could seriously jeopardize the life or health of the patient or the patient's ability to regain maximum function and/or a delay in care would subject the member to severe pain that cannot be adequately managed without the care or treatment requested in the prior authorization).
- 5 business days for routine (all other requests).
Current Authorization List
Before submitting a request form, search HPSM's Prior Authorization List by CPT code or service name to see if you need to get prior authorization.
HPSM regularly updates our list of authorization codes to reflect current clinical guidelines. Archived lists are published on our PAR List Changes page.
Read our notification regarding the most recent code changes: Q3 Prior Authorization and Covered Services Changes Effective 9/1/2021
- For all inpatient admissions, HPSM should be notified within 24 hours or the next business day.
- For admission notification, fax face sheet to 650-829-2060. When attaching clinical information, please place the face sheet before the clinicals.
- Do not submit notification for admissions to observation status. Observation status is direct billable.
- Do not submit requests for services delivered in the emergency room. Emergency room services are direct billable.
- Clinical information for concurrent review should be faxed to 650-829-2068
Unique Authorization Requirements
Unique authorization requirements apply for certain types of healthcare services or products. Please see our page on Specialty Provider Authorizations for more information about:
Frequently Asked Questions
The servicing provider should submit the prior authorization.
Retrospective authorization requests are reviewed to determine if the service was medically necessary using the clinical information submitted by the provider. Providers must also submit documentation about why the request was unable to be submitted prospectively.
Retrospective reviews for inpatient services with appropriate documentation will be accepted up to six months from the date of admission. Retrospective reviews for outpatient services must be submitted, with appropriate documentation, no later than 1 year from the beginning date of service.
Retrospective authorization decisions shall be communicated to the member who received the services, or the member’s designee, within 30 days of the receipt of information that is reasonably necessary to make the determination, and shall be communicated to the provider in a manner that is consistent with current regulations.
In the comment box on the prior authorization form, include a note indicating that a Letter of Agreement (LOA) is needed.
Please check your fax machine. If you have not received your letter within two days after our turnaround times, please contact the Prior Authorization Department at 650-616-2070 to have one faxed to you.
Facesheets should be faxed to 650-829-2060.