Provider Manual | Section 7

Utilization Management

Utilization Management

HPSM’s Utilization Management Program (“the UM Program”) encompasses management and evaluation of care across the continuum of care. This includes pre-service review and authorization, concurrent and retrospective review of inpatient care including acute care, rehabilitation and skilled nursing, pharmaceuticals, durable medical equipment, and ambulatory services.

The UM Program is designed to promote the provision of medically appropriate care; to monitor, evaluate, and manage resource allocation; and to monitor cost effectiveness and quality of the healthcare delivered to our members through a multidisciplinary, comprehensive approach and process.

Utilization and resource management functions are performed by HPSM’s Health Services Department. The Health Service Department’s vision is that services are designed around the member’s journey in the healthcare system with the goal to improve the member’s experience and health outcome.


UM staff are available by telephone between 8:00 a.m. and 5:00 p.m., Monday through Friday at 650-616-2828 and outpatient line at 650-616-2070.

After-hours requests for expedited review will be reviewed by the on-call clinical manager. Communications received after business hours are returned on the next business day. Communications received after midnight on Monday through Friday are responded to on the same business day. HPSM can also accept toll free calls by calling 1-800-750-4776.

Delivery System

HPSM fulfills its mission in San Mateo County because of its successful partnership with outstanding healthcare delivery partners. Medical services are delivered to our members through our directly contracted provider network. While HPSM does not contract directly with its pharmacy network, HPSM’s delegates this responsibility to its contracted pharmacy benefits manager, SS&C for CareAdvantage, HealthWorx, and ACE members. For Medi-Cal members, pharmacy benefits are managed by DHCS in partnership with Magellan Medicaid Administration (Magellan), its delegated pharmacy benefits manager.

Scope of Services

HPSM provides a comprehensive scope of acute and preventive care services for San Mateo County’s MediCal, HealthWorx and dually eligible population. Certain services are not covered by HPSM or may be provided by a different agency. These are:

  • Pharmacy benefits for Medi-Cal members are administered by the Department of Health Care Services in partnership with Magellan, its delegated pharmacy benefit manager. This does not apply to Medi-Cal pharmacy services that are billed as a medical and/or institutional claim as these are still administered by HPSM.
  • Certain mental health services are administered by the San Mateo County Behavioral Health and Recovery Services (BHRS) for Medi-Cal. HPSM contracts with San Mateo County’s Behavioral Health and Recovery Services division for services for its other lines of business.
  • California Children’s Services (CCS) is a statewide program that treats children with certain physical limitations and chronic health conditions or diseases. CCS authorizes care and in San Mateo County, HPSM pays for medical services and equipment provided by specific specialists. The CCS program is funded with State, County, and Federal tax monies, along with some fees paid by parents or guardians.
  • Childhood Health and Development Program (CHDP) is managed at the County level.
  • Enhanced Care Management (ECM) for Medi-Cal members is a statewide benefit. ECM offers a whole person, interdisciplinary approach to care that addresses the clinical and non-clinical needs of high need and/or high-cost members through systematic coordination of services and comprehensive care management that is community-based, interdisciplinary, high-touch, and person-centered. ECM will be offered to specific target populations. HPSM administers this benefit through ECM contracted providers who are community-based entities with experience and expertise providing intensive, in-person care management services to individuals in one or more of the Populations of Focus for ECM.
  • Community Supports are optional services or settings that are offered to Medi-Cal and CareAdvantage members in place of services or settings covered under Medi-Cal. Community Supports is not a benefit but are medically appropriate and cost-effective alternative services with the goal to improve the health outcomes and quality of life experienced by high risk Medi-Cal recipients by addressing Social Determinants of Health (SDOH). Community Supports services or settings are administered by HPSM contracted Community Support providers.
  • HPSM works with community programs to ensure that members with special health care needs, high risk or complex medical and developmental conditions receive additional services that enhance their medical benefits. These partnerships are established through special programs and specific Memorandums of Understanding (MOU) with certain community agencies including the San Mateo County Health Services Agency (HSA) and the Golden Gate Regional Center (GGRC).

Authority, Accountability and Responsibility

The San Mateo Health Commission (SMHC) and the San Mateo Community Health Authority (SMHA) have ultimate accountability and responsibility for the quality of care and services provided to HPSM members. The Commission holds the Chief Executive Officer (CEO) and the Chief Medical Officer (CMO) accountable and responsible for the quality of care and services provided to members. The CMO ensures separation of medical services from fiscal and administrative management to assure that medical decisions will not be unduly influenced.

The CEO allocates financial and employee resources to fulfill the program objectives. The CEO delegates authority, when appropriate, to the CMO. The CEO shall ensure that the QMP satisfies all remaining requirements of the Quality Improvement (QI) Plan, as specified in the state contract.

The CMO:

  • Is responsible for the Utilization Management Program. The CMO is also responsible for the Quality Management Program. At least quarterly, the CMO presents reports on Health Services activities to the Utilization Management Committee. The CMO chairs the Utilization Management Committee that reports to the Senior Executive team. The CMO works in conjunction with the CEO to oversee the quality reporting matrix that includes Utilization Management oversight, development of QI studies, and follow up on identified quality of care issues.
  • Is the CEO’s designee in the day-to-day implementation of Utilization Management and is responsible for ensuring that the program is properly developed, implemented, and coordinated.
  • Is responsible for day-to-day management and oversight of the utilization review process for all product lines for all members. The CMO works closely with the Care Coordination Unit Manager to assure members receive high quality, medically necessary care in a way that balances individual need and cost effectiveness in the short and long term.
  • Is responsible for the overall coordination of planning and evaluation services, including contract requirements and coordination of external quality review requirements. As part of this function, the CMO works in collaboration with the Chief Compliance officer to ensure that HPSM meets the requirements set forth by the Department of Health Care Services (DHCS), Department of Health Services Managed Medi-Cal Division (DHS/MMCD), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid (CMS), and the Managed Risk Medical Insurance Commission (MRMIB). HPSM’s Compliance and Regulatory Affairs Department works in collaboration with HPSM’s functional areas, such as Utilization Management and Grievance and Appeals, to evaluate the results of performance audits and to determine the appropriate course of action to achieve desired results. In addition, the CMO oversees the development and amendment of HPSM policies and procedures related to Utilization Management and Health Services to ensure adherence to state and federal requirements. Lastly, functions relating to fraud investigations are handled by the Compliance and Regulatory Affairs Department.

The Care Coordination Unit Manager is accountable to plan, organize, develop, and manage the care coordination system in Health Services. The Care Coordination Unit Manager’s primary focus is on high-risk members as identified through emergency and inpatient recidivism and those members requiring complex medical care coordination. The Care Coordination Unit Manager interacts regularly with the provider community and outside agencies including but not limited to the Regional Centers, California Children’s Services, County Mental Health, the County public hospital and Aging and Adult Services.

The Director of Pharmacy has management responsibility for overseeing pharmacy benefits operations activities for HealthWorx and CareAdvantage, including formulary management, cost containment and reimbursement strategies, program administrative leadership, supervision of pharmacy staff, program development and policy enhancement.

The Department of Health Care Services (DHCS) oversees the pharmacy benefit operations for Medi-Cal through its pharmacy benefit manager Magellan.

The Provider Network Manager is responsible for provider network development, contracting, and provider relations management for contracted and non-contracted providers. The Provider Services Department is responsible for assuring that providers can efficiently deliver services to members and receive prompt reimbursement for services performed. The Provider Network Liaisons perform provider education and assist providers in problem resolution.

About the Utilization Management Program

The purpose of the Utilization Management Program is to define and describe HPSM's multidisciplinary, comprehensive approach to managing resource allocation through systematic monitoring of medical necessity and quality while maximizing the cost effectiveness of the care and service provided to members.

The Utilization Management Program will ensure that:

  • HPSM Health Services Utilization Management (UM) review staff utilize nationally recognized standard criteria and informational resources to determine the medical necessity of healthcare services to be provided (e.g., Medi-Cal Manual of Criteria issued by the State of California, Milliman Care Guidelines).
  • HPSM Health Services UM review staff, that includes physicians, licensed nurses, and unlicensed trained employees, carry out the responsibilities designated for their level of expertise within their respective scope of practice, and as defined in their Job Position Descriptions.
  • HPSM Utilization Management Program collaborates with the HPSM Quality Assessment and Improvement program to ensure ongoing monitoring and evaluation of quality of care and service, and continuous quality improvement.
  • At least annually, the Utilization Management Program description, policies, and procedures are reviewed at one of the monthly medical management meetings, attending by senior management and it is also reviewed at the Quality Management Oversight Committee meeting. The UM Program is revised if necessary.
  • The Care Coordination Unit/Integrated Care Management play a role in supporting Utilization Management by helping ensure members have access to the appropriate care and services within their health plan benefits evaluating the medical necessity and appropriateness of the member’s services. Care Coordination Unit/Integrated Care Management staff are knowledgeable about each member’s benefits and work to facilitate optimal use of those benefits keeping the member at the center of their care while overseeing that services are appropriately utilized and meeting the member’s needs.

The Utilization Management Program shall endeavor to promote the delivery of high-quality care in the most cost- effective manner for HPSM's members, and thus contribute to the achievement of the HPSM mission. The Utilization Program goals and objectives are to:

  • Improve the quality of care delivered to members by ensuring they receive the appropriate level and mix of medical services in the most appropriate setting- The right service at the right time at the right place for the right reason.
  • Facilitate communication and develop positive relationships between members and contracted providers by providing timely appropriate utilization review processing.
  • Identify members with special needs and ensure that appropriate care is delivered to them through collaboration with county partners. This will reduce overall healthcare expenditures by developing and implementing effective preventive care and health promotion programs.
  • Identify actual and/or potential quality issues during utilization review activities and refer to the CMO.
  • Ensure compliance with regulatory agencies.

UM staff work collaboratively with contracted healthcare providers in the community to assure the delivery of appropriate, cost effective, quality evidence-based healthcare. The Utilization Management Program necessitates the cooperative participation of all HPSM contracted healthcare providers, including physicians, allied healthcare professionals, hospitals, outpatient facilities as well as members to ensure timely and effective delivery of healthcare services. Several collaborative projects between the plan and our county partners have been implemented. These collaborative projects identify members with special needs and ensure that appropriate care is delivered to them. Collaborative projects include but are not limited to, the Care Transition program. The Care Transition project focuses on providing well-coordinated community-based senior services, including limiting gaps in care between inpatient and outpatient and community-based senior services. The Care Transition project’s model is to improve transitional care between the hospital and home or skilled nursing facilities.

The Health Services Department is responsible for all UM processing for members in all programs. Leadership is provided by the CMO, who directly supervises the Utilization Review Manager. The Utilization Manager directly supervises the UM Nursing review staff and Authorization Specialists. The Director of Pharmacy supervises the pharmacy staff and day to day operations of pharmacy benefit management for HealthWorx and CareAdvantage while the Department of Health Care Services supervises the administration of the pharmacy benefits for Medi-Cal members. The Care Coordination Unit Manager supervises the Nurse Case Managers, Care Coordination Technician, and the day-to-day management of the Care Coordination Unit/Integrated Care Management.

The Health Services Department collaboratively contributes to the development and implementation of the HPSM Utilization Program, as well as supporting policies and procedures. This Utilization Management Program is developed in compliance with the California Department of Health Services, the Center for Medicare and Medicaid Services (CMS) regulations for Medi-Cal and Knox-Keene regulations 1300.70, and SB 59.

The Utilization Program is reviewed and evaluated for effectiveness at least annually by the CMO. Recommendations for revisions and improvement are made as appropriate and the subsequent annual Utilization Program is based on the findings of the annual program evaluation.

UM staff work collaboratively with contracted healthcare providers in the community, to assure the delivery of appropriate, cost effective, quality evidence-based healthcare. The Utilization Management Program necessitates the cooperative participation of all HPSM contracted healthcare providers, including physicians, allied healthcare professionals, hospitals, outpatient facilities as well as members to ensure timely and effective delivery of healthcare services. Several collaborative projects between the plan and our county partners have been implemented. Using a proactive approach, these collaborative projects identify members with special needs and ensure that appropriate care is delivered timely and efficiently. Collaborative projects include, but are not limited to, complex care management programs that address high risk care management of the medically frail dually eligible CareAdvantage population, the Care Transitions program, and developmentally disabled targeted case management. Additionally, the program integrates a Clinical Pharmacy Outreach Program (CPOP), the Long-Term Care Clinical Management program, In Home Physician program, Medication Therapy Management and disease management.

Committee Organization and Reporting Structure

The structure of the Utilization Management Program is designed to promote organizational accountability and responsibility in the identification, evaluation, and appropriate utilization of the HPSM healthcare delivery.

Additionally, the structure is designed to enhance communication and collaboration on UM issues that affect entities and multiple disciplines within the organization.

The Organization Chart and the Program Committees Reporting Structure outlines HPSM’s governing body, HPSM senior management, as well as committee reporting structure and lines of authority. Position job descriptions and Committee policies/ procedures define associated responsibilities and accountability.

HPSM Utilization Management Workgroup

The Utilization Management Workgroup promotes the optimal utilization of healthcare services while protecting and acknowledging member rights and responsibilities, including their right to appeal denials of service. The workgroup monitors the utilization of healthcare services by HPSM members in all programs to identify areas of under or over utilization that may adversely impact member care. The Workgroup meets twice a month.

Role and Responsibility

  • Provides coordination of UM functions.
  • Provides oversight for appropriateness and clinical criteria used to monitor care and services provided to HPSM members.
  • Monitors data and reports and identifies opportunities for improvement of internal processes and systems.
  • Measures and documents effectiveness of actions taken.
  • Review and evaluation of data to identify under or over utilization patterns.
  • Review care management issues related to continuity and coordination of care for members.

Care Coordination Meetings

HPSM meets at least quarterly with other community partners to address issues regarding the coordination of healthcare delivery services involving the San Mateo County Mental Health Plan Behavioral Health and Recovery Services (BHRS), Golden Gate Regional Center (GGRC), and Aging and Adult Services (AAS). HPSM does not provide CHDP services but works closely with this agency to coordinate services. Memoranda of Understanding (MOU) exists between each of these community partners, which require quarterly meetings to clarify systems issues and to coordinate the care of complex cases. The MOU clarifies responsibilities and establishes protocols and procedures for the exchange of information and maintaining confidentiality. These quarterly coordination meetings are attended by representatives of each of the respective organizations.

System-wide issues and specific cases are addressed to promote continuity and coordination of care between the medical and behavioral healthcare providers.

Peer Review Committee/Physician Advisory Group (PRC/PAG)

The PRC/PAG provides guidance and peer input into the HPSM practitioner and provider selection process and determines corrective actions as necessary to ensure that all practitioners and providers that serve HPSM members meet generally accepted standards for their profession or industry. The PRC/PAG shall review, investigate, and evaluate the credentials of all internal HPSM medical staff for membership and maintain a continuing review of the qualifications and performance of all internal medical staff. The PRC/PAG includes practicing physicians from the contracted healthcare provider network. The PAG meets on a bimonthly basis while appropriate peer review committees meet on an ad-hoc basis as needed. The Chairperson of this committee is a physician member of the Commission.

Role and Responsibilities

  • Provides linkage with practicing physicians in the community for input to HPSM Quality and Utilization Programs.
  • Reviews of quality-of-care issues.
  • Peer review.
  • Reviews provider trends as related to UM and Quality issues.
  • Takes corrective actions, when necessary, to improve provider performance and optimize systems and processes.

PCP-to-Specialist Referral Process

For Non-ACE Members

Referrals are only required for members to see non-participating (out-of-network) plan specialist providers for evaluation and treatment. If you believe a member needs to see a specialist, the PCP is responsible for coordinating that referral for the member. The PCP is to use their facility or practice’s standard referral process. For out-of-network specialists, it will be their responsibility to follow HPSM’s prior authorization process to request services for the member.

PCPs should make every effort to refer HPSM members to a participating specialist listed in our provider directory. The HPSM provider directory, updated annually, is available on our website and in hard copy format. Please ask HPSM Provider Services for a hard copy.

HPSM realizes that there are unique circumstances in which our participating provider network may not cover a particular specialized medical service that is medically necessary for evaluation and/or treatment of a member. In these situations, the non-participating provider will need to follow HPSM’s prior authorization process.

Referrals through HPSM are not needed for members to see doctors for sensitive services, like OB/GYN services, family planning services, sexually transmitted disease/HIV testing/counseling services, or for emergencies.

The following services do not require a referral:

  • E&M codes rendered in a SNF.
  • Emergency care.
  • Preventive services.
  • Minor Consent services – Minors without their parents’ consent may receive the following services:
    • Services related to sexual assault.
    • Pregnancy and pregnancy related services.
    • Family planning services.
    • Drug and alcohol abuse counseling*.
    • Outpatient mental health services*.
  • Obstetrical services and family planning services:
    • Pregnancy planning.
    • Birth control.
    • Prevention of sexually transmitted diseases.
    • Confidential testing for venereal disease.
    • HIV counseling and testing.
  • Abortion services.
  • Services from an Indian Health Services (IHS) provider.
  • “Limited Services":
    • Chiropractic.
    • Podiatry.
    • Acupuncture** (Medicare non-covered benefit).
    • Prayer or Spiritual Healers.
    • Vision (Medicare non-covered benefit).
    • Eyeglasses** (Medicare non-covered benefit).

Medi-Cal members are limited to two office visits for each of these specialist services in a single month. For additional visits in a single month or for any procedures (other than office visits), please refer to the HPSM website for the most up-to-date prior authorization requirements.

*Minor consent services: Member must be 12 years old or greater to be able to consent for drug and alcohol abuse treatment. Member must be 12 years old or greater and mature enough to consent and is the victim of incest or child abuse or would present a threat of serious physical or mental harm to self or other without treatment for outpatient mental health services.

ACE members

The San Mateo County ACE program is available to uninsured residents of San Mateo County who are not eligible for coverage through Medicare, Medi-Cal, private insurance, or other third-party coverage. ACE is a coverage program and is not considered health insurance. Services are primarily available through the San Mateo Medical Center and Ravenswood Family Health Center. A referral to any other provider is only through the RAF prior authorization process DME, home health care services, and medical supplies do not require a Referral Authorization Form (RAF). You can find the ACE referral authorization form here: 

Prior Authorizations

Prior authorization is intended to ensure that the requested service is covered by the member's scope of benefits, that the provider of service is participating, and that the services are medically necessary. Services will also be reviewed to ensure that the most appropriate setting is being utilized and to identify those members who may benefit from our Care Coordination Unit/Integrated Care Management programs. Prior authorization is subject to a member’s eligibility and covered benefits at the time of service.

An authorization must be obtained from HPSM prior to rendering the requested service to ensure reimbursement. Reimbursement is still subject to member eligibility on the date of service.

Please check the member’s eligibility using any of the methods listed in “Section 2: Customer Support” before providing any service. In the event of an emergency, HPSM must be contacted within 24 hours, or on the next business day.

Prior authorization requirements may apply to all lines of business. Please refer to the HPSM website for the most up-to-date information about prior authorization requirements.

Prior authorization is not required when HPSM is secondary, and the primary payer approved the claim unless the primary carrier is a non-Medicare payer and HPSM’s liability after coordinating benefits is over $25,000.

Providers have a right to receive a free copy of any criteria used to make prior authorization and appeal decisions by HPSM. This includes a copy of the actual benefit provision, guideline, protocol, or criteria that we based our decision on. Call the UM department at 650-616-2133 for non-drug authorization decisions or 650-616-2088 for drug decisions.

Medical Services

Primary care physicians, specialty care providers, and ancillary providers who identify a need for medical services for an eligible HPSM member should submit their orders or prescriptions to a rendering provider. The rendering provider should complete a prior authorization form (PAR) for medical services that require a prior authorization.

The PAR is to be used to document needed identification information. Depending on the complexity of the request, clinical information sufficient to make a medical necessity determination should be documented on this form. In most cases, a copy of a recent office note or consultation summarizing the medical needs of your patient will help us to rapidly process the request. Information which can facilitate prior authorization determinations includes the following elements, as relevant to each individual case:

  • Patient characteristics such as age, sex, height, weight, or other historical and physical findings pertinent to the condition proposed for treatment.
  • Precise information confirming the diagnosis or indication for the proposed medical service.
  • Details of treatment for the index condition, or any related condition, including names, doses, and duration of treatment for pharmacotherapy, and/or detailed surgical notes for surgical therapy.
  • Appropriate laboratory or radiology results.
  • Office or consultation notes related to the proposed medical service.
  • Peer-reviewed medical literature, national guidelines, or consensus statements of relevant expert panels.
  • The medical need for care by a provider outside of the HPSM network.
  • Applicable CPT-4 and ICD-10 diagnosis codes.
  • Applicable CPT/HCPCS code(s) for the requested service/procedure.
  • Complete facility and service information (including facility provider number and location).
  • Requested length of stay for all inpatient requests.
  • Proposed date of procedure for all outpatient surgical requests.

Whenever possible, we ask that providers submit requests for prior authorization to HPSM seven to 10 business days in advance of scheduled procedures. This will ensure that our UM staff have enough time to process and review your requests, and, if needed, obtain appropriate additional information, without a need to potentially delay care to your patient. Fax all PAR requests to fax number 650-829-2079.

Urgent Requests receive special attention. HPSM makes every effort to return authorization determinations quickly. Urgently needed care should never be delayed while awaiting prior authorization. Please do not hesitate to ask to speak directly to the CMO if you have any concerns that our process is interfering with the care your patient requires. Urgent PARs may be faxed to 650-829-2079.

The "Urgent" designation is intended for cases in which the requested service must be provided as quickly as possible to avoid harm to the patient. At times, requests may be received as urgent because elective services were scheduled, but authorizations were not requested in advance. We will do our best to respond to such requests but may have to ask that such procedures be rescheduled if there is insufficient time to obtain the clinical information and complete the required review.

Definition of an “Urgent Request” is one in which the requested service is medically needed within 72 hours of submission. Abuse of urgent prior authorization requests will be monitored. Please note: The autoreply, or automated confirmation of receipt, will only work if the provider’s fax number is not blocked. (If the provider does not wish to receive an auto-reply message, he/she should block his/her office fax number, either through the local phone provider or through the fax machine options menu.)

Note: Urgent prior authorization requests faxed to other fax numbers at HPSM will not be forwarded to Health Services and will not receive an autoreply. Please use the HPSM Health Services Fax line for urgent prior authorization requests.

For questions regarding the status of a submitted prior authorization request, or questions regarding the authorization process, you may call HPSM Health Services Department at 650-616-2070. Calls are answered by Prior Authorization Specialists to facilitate communication of essential information. Peak telephone call volume typically occurs in the late morning or early afternoon on Mondays and Fridays. Telephone response times are generally best at other times of the day. HPSM Health Services Department hours are from 8:00 a.m. to 5:00 p.m. Monday through Friday, excluding company holidays.

For questions related to medical Injectable drug or physician administered drugs (PADs) requests, you may call the HPSM Pharmacy Services Department at 650-616-2088. The HPSM Pharmacy Services Department hours are from 8:00 a.m. to 5:00 p.m. Monday through Friday, excluding company holidays.

Completed Prior Authorization Request (PAR) forms and documentation should be mailed to:

Health Plan of San Mateo
Health Services Department ATTN: PAR Processing
801 Gateway Boulevard, Suite 100
South San Francisco, California 94080

Communication of approval of Urgent Requests will be via call.

Dental Services

Primary care dental providers and specialty dental providers who identify a need for dental services that are listed on the prior authorization list for an eligible HPSM member, should complete a prior authorization form. The prior authorization is used to determine a member’s eligibility for services requested. Additional information is requested to make determination which can include but not limited to: dental x-rays, dental images, periodontal chart, and/or a narrative.

Please refer to HPSM website for most up to date prior authorization form details as well as the list of services that require an authorization and supporting documentation requested.

All dental prior authorizations can be sent electronically or sent via mail.

For urgent authorizations or to check the status of a submitted prior authorization, please call 650-616-1522 or email You can also check the status of an authorization through the provider portal.

For paper dental prior authorization requests, please submit to:

HPSM Dental
PO Box 1798
San Leandro, California 94577

Prescription Medications


For more information regarding the prior authorization process related to Medi-Cal pharmacy services, please visit the Medi-Cal Rx website at or contact the Medi-Cal Rx Customer Service Center at 1-800-977-2273.

CareAdvantage and HealthWorx

HPSM has a process in place to ensure that procedures for pharmaceutical management promote the clinically appropriate use of pharmaceuticals and to make medical necessity exceptions to the HPSM formulary (HPSM Approved Drug List).

The HPSM Pharmacy Staff and the Pharmacy and Therapeutics Committee are responsible for development of HPSM CareAdvantage and HealthWorx Approved Drug Lists, which are based on sound clinical evidence and reviewed at least annually by actively practicing practitioners and pharmacists. Updates to the HPSM CareAdvantage and HealthWorx Approved Drug Lists are posted on the HPSM website.

  • If the following situations exist, HPSM will consider the appropriateness of prior authorization of non-formulary drugs:
  • No formulary alternative is appropriate, and the drug is medically necessary.
  • Member has failed treatment or experienced adverse effects on formulary drugs.
  • Member’s treatment has been stable on a non-formulary drug and change to formulary drug is medically inappropriate.

To request a prior authorization for outpatient medication not on the HPSM CareAdvantage and HealthWorx Approved Drug List, the physician or physician agent must provide documentation to support the request for coverage. Documentation must be provided on the prescription request form, available on the HPSM website, which is submitted to HPSM’s pharmacy unit for review. The initial review is based on prior authorization guidelines approved and established by HPSM.

The pharmacy review staffs profiles drug utilization by member to identify instances of polypharmacy that may pose a health risk to the member. Prescribing practices are profiled by practitioner and specialty groups to identify educational needs and potential over utilization. Additional prior authorization requirements may be implemented for physicians whose practices are under intensified review.

Extension of a Prior Authorization Request

After a submitted prior authorization request is reviewed by a UM Review nurse and determined to require additional information to evaluate the medical necessity of the requested service, a notice will be sent to the originator of the request for the specific information needed within 14 days.  The member is also notified of the deferral.

If no information is received or the information received does not address the requested information, the prior authorization request will be denied.  Please respond to the request for additional information accurately and timely, as HPSM is only allowed to extend a prior authorization request once. Notifications of a prior authorization request administrative denial are sent to both the originator of the request as well as the member.

Denied Requests

Prior authorization requests denied for medical necessity must be reviewed by the Medical Director or Clinical Pharmacist (for medical injectable drugs only). Medically necessary health care services are those services provided by a licensed health care provider to diagnose or treat an illness, injury, or medical condition which the HPSM Medical Director or Clinical Pharmacist determines to be:

  • Appropriate and necessary for the diagnosis, treatment, or care of a medical condition.
  • Not provided for cosmetic purposes.
  • Not primarily custodial care (including domiciliary and institutional care).
  • Not provided for the convenience of the member, the member's attending or consulting physician or another provider.
  • Performed in the most efficient setting or manner to treat the member's condition.
  • Necessary as determined by an order of the court.
  • Being within standards of good medical practice as recognized and accepted by the medical community. Non-acute care and treatment rendered when there is no reasonable expectation of the member's improvement or recovery as determined by the HPSM CMO, using generally accepted medical standards shall be considered not medically necessary. Denial letters will be issued in accordance with DMHC/DHCS and CMS mandates and time frame standards.

Retroactive authorizations

Retroactive 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 one 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.

Care Coordination/Integrated Care Management Program

The HPSM Care Coordination Unit/Integrated Care Management program coordinates services and complex care for the best clinical and functional outcomes for members. Through the inpatient concurrent review process, Care and Transition Coordination staff work with members, their families, Primary Care Physicians (PCPs), specialists and community resources to coordinate a comprehensive plan of care. HPSM Care Coordination Unit/Integrated Care Management staff understand the benefits available to each member and can facilitate the optimal use of those benefits. Participation in Care Coordination Unit/Integrated Care Management is voluntary, and a member can opt in or out at any time.

Not all patients benefit from Care Coordination Unit/Integrated Care Management services. Patients receiving care from a single physician often do not need an outside coordinator for that care. However, with increasing case complexity, and increasing numbers of loosely affiliated care providers, many patients with complex care needs benefit by having a designated Care Coordination Unit/Integrated Care Management staff member.

HPSM identifies cases for Care Coordination Unit/Integrated Care Management prospectively through health status surveys and referrals from care providers and concurrently through the analysis of claims and hospital admissions history. We also request that providers notify our Care Coordination Unit/ Integrated Care Management staff of complex cases amenable to Care Coordination Unit/Integrated Care Management.

Once a case is identified, the Care Coordination Unit/Integrated Care Management staff will contact the treating providers to establish a case file. The Care Coordination Unit/Integrated Care Management staff member will work with the provider to coordinate services, identify benefits that have not been fully utilized and can advise the treatment team of important coverage limitations that may apply.

Care Coordination Unit/Integrated Care Management staff will generally become involved with:

  • Transfers to tertiary care facilities or centers of excellence.
  • Admissions or referrals to non-participating providers or facilities.
  • Members with ongoing care needs in a rehabilitation center, skilled nursing facility or home care.
  • Members with frequent emergency room visits.
  • Continuing care following discharge against medical advice.
  • Members with ongoing complex care needs or high-cost diagnosis including but not limited to:
    • End stage renal disease requiring dialysis or transplant.
    • Chronic pain.
    • Multiple sclerosis, amyotrophic lateral sclerosis, and other debilitating neurologic conditions.
    • Hemophilia.
    • High-risk pregnancies.
    • Cancer.
    • HIV/AIDS, chronic viral infections.
    • Coordination of care for members requiring services from community agencies such as: The Early Intervention Program through Golden Gate Regional Center, rehabilitation programs, tuberculosis treatment programs and HIV special needs programs.

Providers may contact HPSM’s Care Coordination Unit/Integrated Care Management Unit directly at 650-616-2060 or utilize the Case Management Referral form located on our website. Care Coordination Unit/Integrated Care Management staff can aid in arranging care and/or in advising on resources that meet a member's needs.

Self-Referred Care

HPSM members who meet the criteria outlined below do not need a referral for the following health services provided through a participating provider:

Screening Mammography

The United States Preventive Services Task Force recommends a screening mammography every two years with or without clinical breast examination among women age 50-74. HPSM covers screening mammography for women over the age of 40 and encourages women to discuss the potential risks and benefits of mammography with her primary care provider. Women members of HPSM may self-refer for mammography after the age of 40. A participating diagnostic imaging provider must be used for this service. The testing center will require a prescription from a requesting physician.

OB/GYN Services

HPSM members may self-refer for routine primary and preventive OB/GYN services, care related to a pregnancy, or for the care of acute gynecological conditions, if that care is provided by a participating OB/GYN provider. HPSM will also cover the cost of care for conditions identified in the self-referred visit. It is expected that the OB/GYN physician will send to the member's primary care provider a summary of the services and treatment plan as well as copies of screening (pap smear, mammogram) or diagnostic tests performed.

Selected Routine Outpatient Diagnostic Services

The following procedures, when performed at a participating HPSM outpatient hospital or freestanding radiology facility do not require prior authorization. The ordering physician simply issues a prescription to the member and sends them to a participating facility. The primary care provider simply sends a referral to the participating specialist for the service to be provided.

  • Audiology evoked potential studies (limited service under CareAdvantage).
  • Cardiac procedures (electrocardiography and cardiac stress tests).
  • OB/GYN testing (fetal non-stress test, amniocentesis, cardiocentesis, chorionic villus sampling, fetal contraction test, fetal scalp blood sampling).
  • Neurological studies (electroencephalograms, EMG, nerve conduction studies).
  • Pulmonary function tests.

Medi-Cal and HealthWorx Members have the option to self-refer for additional services listed below.

Family Planning

Members may self-refer for family planning services through a participating provider. Family planning services include advice for birth control, pregnancy tests, sterilization, or an abortion, tests for sexually transmitted infections, HIV testing and counseling, a breast cancer exam or a pelvic exam. Medi-Cal members may go outside of the HPSM network to any provider that accepts Medi-Cal.

HIV Testing and Counseling

Members can self-refer for HIV testing and counseling any time they have family planning services, or through one of the participating family planning providers. Medi-Cal members may go outside of the HPSM network to any provider that accepts Medi-Cal.

Tuberculosis Diagnosis and Treatment

Members may self-refer for Tuberculosis Diagnosis and Treatment to a county public health agency for diagnosis and/or treatment. Members can choose to use either their HPSM provider or the county public health agency for diagnosis and/or treatment, including Directly Observed Therapy (DOT).


Members may receive immunizations through the primary care provider or self-refer to public health clinics for immunizations. Public health clinics will make every effort to verify with the member's primary care provider that the member has not already received the immunization and supply the health plan with documentation of services along with the claim.

Emergency and Urgent Care

The primary care provider is responsible for the care of their patients 24 hours a day, seven days a week. The primary care provider or designee must be available in their office or via phone or answering service to appropriately triage and evaluate all non-emergent care.

HPSM members with a medical emergency should go to the nearest emergency room for care. HPSM provides coverage for emergency services that meet the "prudent layperson" standard without prior authorization of these services. In addition, HPSM will provide coverage for any emergency room service authorized by the primary care provider or HPSM authorized representative. The member contract requests that members notify their primary care provider and HPSM within 48 hours of receiving care for an emergency. Conditions that do not meet the specified definition of medical emergency below including urgent care services require a referral by the member's primary care provider.

HPSM and the prudent layperson standard defines a medical emergency as the sudden, unexpected onset of a medical or behavioral condition causing symptoms of sufficient severity that a prudent layperson with an average knowledge of medicine and health could reasonably expect, in the absence of immediate medical attention, to result in:

  • Serious jeopardy to the afflicted person's life or health,
  • Serious jeopardy to the life or health of a pregnant woman’s unborn child.
  • In the case of a behavioral condition, placing the health of such person or others in serious jeopardy.
  • Serious impairment to the afflicted person's bodily functions.
  • Serious dysfunction of any bodily organ.
  • Disfigurement.

Some examples of medical emergency include apparent heart attack/stroke, difficulty in breathing, severe bleeding, blackout, convulsions, apparent poisoning, or fracture.

If a member self-refers to the emergency room, the HPSM Medical Director/designee will determine whether the presentation of symptoms was consistent with the above prudent layperson criteria and will state reasons in writing whenever this coverage is denied.

Primary care providers notification is not required for emergency care, but coverage can be ensured if the primary care provider authorizes such care.

Behavioral Health Management

HPSM ensures that members with coexisting medical and behavioral healthcare needs have adequate coordination and continuity of their care throughout the network.

HPSM works closely with the San Mateo County Mental Health Plan Behavioral Health and Recovery Services (BHRS), as well as other county programs such as Golden Gate Regional Center, and California Children’s Services to coordinate medical and behavioral care for members.

Continuity and coordination of behavioral healthcare may involve HPSM communicating directly and/or coordinating care between primary care providers and behavioral health providers. The HPSM Care Coordination Case Manager and other related Health Services staff are responsible for coordinating services with San Mateo County BHRS to ensure that individual members with coexisting medical and behavioral disorders receive appropriate treatment in the appropriate ambulatory and/or inpatient setting.

Long Term Care

HPSM is responsible for long term care (LTC) authorizations, utilization management and payment of facility room and board charges. Approximately 1,300– 1,400 HPSM members are residents of long-term care facilities. HPSM has over 100 contracted LTC facilities in San Mateo County and surrounding counties.

HPSM administers these services in accordance with current Medi-Cal guidelines. HPSM is administratively and financially responsible for the authorization of LTC prior authorization requests for all Medi-Cal eligible beneficiaries with a County Code of 41 (San Mateo) and health plan number (HCP) 503. LTC nursing facilities send all prior authorization requests for services for facility room and board services provided to HPSM members to HPSM’s Health Services Department. HPSM’s Health Services Department processes prior authorization requests for members who require admission to LTC facilities, including free standing or distinct part Skilled Nursing Facilities (SNFs), Intermediate Care Facilities (ICFs), ICF/Developmentally Disabled (ICF/DD), ICF/DD-Habilitative (ICF/DD-H), ICF/DD-Nursing (ICF/DD-N) or sub-acute Facilities-Adult/Pediatric. Prior authorization requests are processed in accordance with the applicable requirements of the California Code of Regulations, Manual of Criteria for Medi-Cal Authorization, the California Welfare and Institutions Code and HPSM’s Policies and Procedures in accordance with contractual agreements.

Financial Responsibility Related to Long Term Care

The daily rate charge for long term care services is the responsibility of HPSM. The admitting facility is responsible for obtaining the necessary authorization for the facility daily rate from HPSM’s Health Services Department according to the long term care prior authorization request submission requirements. HPSM continues to be responsible for authorizing, monitoring, and reimbursing medically necessary Medi-Cal covered services that are not included in the daily rate.

Preadmission Screening and Resident Review (PAS/PASARR)

Each HPSM Medi-Cal recipient applying for nursing facility admission is subject to PAS/PASARR Level I screening or evaluation either prior to admission or on the first day for which HPSM Medi-Cal reimbursement is requested. The admitting nursing facility is responsible for performing the evaluations. The admitting nursing facility is also responsible for making a referral for Level II evaluation when appropriate. Welfare and Institutions Code Section 9390.5 has required Preadmission Screening for every Medi-Cal recipient applying for admission to a nursing facility to determine if the recipient’s condition requires institutionalization in a nursing facility or whether he/she could remain in the community with support services. The nursing facility will utilize PAS/PASARR Level I Screening Document (DHS 6170), Long Term Care Prior Authorization Request (Form 20-1), Minimum Data Set (MDS) Full Assessment Form) or Minimum Data Set (MDS) Quarterly Assessment Form, and PAS/PASARR Monthly Statistical Report. The nursing facility will comply with applicable regulations in the Code of Federal Regulations, the Medi-Cal Long Term Care Provider Manual, the Welfare and Institutions Code and Title 22.

Plan of Care in Long Term Care

All HPSM members admitted to long term care facilities shall have an individually written plan of care completed, approved and signed by a physician pursuant to Title 42, Code of Federal Regulations. The plan of care shall be maintained in the member’s medical record at the long term care facility.

Long Term Services and Supports (LTSS) Liaison for Intermediate Care Facilities for the Developmentally Disabled (ICF/DD)

LTSS liaisons are trained to identify and understand the full spectrum of Medi-Cal long-term institutional care, including payment and coverage rules. LTSS liaisons serve as a single point of contact for service providers in both a provider representative role and to support care transitions as needed. LTSS liaisons assist in addressing claims and payment inquiries and assist with care transitions among the LTSS Provider community to best support member needs. Please direct questions to our LTSS liaison at

Prior Authorization Required Process and Criteria for Admission

Continued Stay in, and/or Discharge from a SNF, ICF, ICF/DD, ICF/DD-H, ICF/DD-N, and Subacute Adult/Pediatric Facility: HPSM’s Health Services Department will process all request for admission to, continued stays in, or discharge from any long term care facility in accordance with the California Department of Health Services (DHS) standard clinical criteria for levels of services. Each level of care prior authorization requests processing procedure will comply with applicable regulatory requirements.

On Site Prior Authorization Review, Long Term Care

HPSM’s Health Services Department may perform on site review for DP-NFs, Intermediate Care Facilities, and sub- acute sites. On-site review may also be done at free standing nursing facilities, when indicated, e.g., patterns of high service utilization, frequent acute hospitalization of members, large numbers of member complaints/concerns. Prior authorization request requirements will follow Title 22 California Code of Regulations and DHS Manual of Criteria for Medi-Cal Authorization.

Retroactive Authorization for PAR for Long Term Care Facility Daily Rate

HPSM’s Health Services Department shall process all requests for long term care retroactive authorizations and or continued stays for HPSM members in an SNF, ICF, ICF/DD, ICF/DD-H, ICF/DD-N, sub-acute facility–adult or sub-acute facility- pediatric pursuant to the California Department of Health Services standard clinical criteria for a skilled level or care. The long term care will submit the request for long term care prior authorization request with the required clinical information and completed forms to the HPSM Health Services by mail or fax in accordance with applicable requirements of the California Code of Regulations, Title 22.

Quality Improvement Activities for Long Term Care

HPSM’s Quality Improvement program systematically manages the provision and continuous improvement in the quality and care of service provided to all HPSM members. Measures of quality care and service include the following: access to care, appropriateness of care, process of caring, health outcomes, and member and provider satisfaction.

Quality Assessment and Improvement (QAI) activities as related to members residing in long term care facilities will comply with all state and federal requirements as specified in the contract between the state and HPSM. The QAI program focuses on evaluation and improvement of the quality of member care in all settings or levels of care and with primary care and specialty physicians. HPSM is not responsible for any facility oversight as currently carried out by the California Department of Licensing and Certification, or for the California Department of Health Services Field office responsibilities related to the Inspection of Care Adults.

HPSM assists in the identification and communication of potential quality of care issues with other agencies directly involved in coordination of services for members in long term care facilities including, but not limited to, CCS, Mental Health, and Golden Gate Regional Center. In addition, communication to Licensing and Certification, Medi-Cal Operations Division and the LTC Ombudsman Office for potential quality of care issues may be a part of the QAI activities as indicated.

Complaints and Grievances

Long term care facility room and board charges are a Medi-Cal benefit now administered by HPSM. All HPSM members and providers have access to HPSM’s state-approved complaint and grievance process. Members also have access to the State Fair Hearing process at any time. The mechanism by which an long term care facility can resolve member or provider issues related to the provision of Medi-Cal facility services to HPSM members will be amended as needed to include the long term care program services.

Occurrence Reporting to Licensing and Certification

HPSM’s Health Services and Quality Improvement departments shall respond to occurrences, situations and complaints that affect or potentially affect the safety and well-being of HPSM members in long term care facilities by reporting the events to the appropriate regulatory agency for investigation.

Process for Transferring HPSM Members From Long Term Care Facilities to Acute Care Facilities: 

A long term care facility shall be responsible for coordinating an emergent/urgent transfer of a HPSM member to an acute care facility. A long term care facility shall collaborate with all appropriate multidisciplinary team members to facilitate either a planned or emergent/urgent transfer of a HPSM member from a long term care facility to an acute care facility. The long term care facility shall notify HPSM’s Health Services Department of the admission of a HPSM member to the acute care facility on the next business day.

From acute care facilities to long term care facilities: The acute care facility in collaboration with HPSM shall be responsible for all discharge planning aspects of a HPSM member’s transfer to an long term care facility. HPSM’s Health Services Department shall assist in coordinating the discharge planning of the member from an acute care facility to an long term care facility. The acute care facility shall collaborate with all appropriate multidisciplinary team members to facilitate the transfer of the member. The admitting long term care facility shall notify HPSM’s Health Services Department of the admission of the member. The admitting long term care facility shall coordinate the medical and ancillary services with HPSM’s Health Services Department and/or appropriate agency, e.g., California Children Services (CCS) and the local Regional Care Center, as appropriate.

Distinct Part Nursing Facility Authorization

The Hudman v. Kizer court order applies to all eligible Medi-Cal recipients/HPSM members in need of longterm skilled nursing care.

Distinct Part/Nursing Facilities (DP/NF) shall be reimbursed at the DP/NF rate when the medical necessity for long term nursing care has been documented and all administrative requirements have been met as described in the Department of Health Care Services (DHCS) Long Term Care manual.

Leave of Absence

A Leave of Absence (LOA) may be granted to a recipient in a Nursing Facility (NF) Level A or NF Level B, NF Level A-DD- N and NF Level A-DD-H in accordance with the recipient’s individual plan of care and for the specific reasons outlined in the DHCS Long Term Care manual.

Leaves of absence may be granted for the following reasons: a) a visit with relatives or friends; b) participation by developmentally disabled recipients in an organized summer camp for developmentally disabled persons.

Bed Hold for Acute Hospitalization

If a recipient is admitted to an acute care hospital, a Bed Hold (BH) may be permissible under the conditions outlined in the DHCS Long Term Care manual.

Summer Camp Leave Bed Hold Reimbursement

Skilled nursing and intermediary care facilities may receive reimbursement for developmentally disabled (DD) recipients attending summer camp.

To qualify for reimbursement, the facility must meet the following criteria:

  1. the patient’s attendance at camp is prescribed by a licensed physician and approved by the appropriate regional center for the developmentally disabled.
  2. the patient is not discharged from the facility while attending camp.
  3. the facility holds the patient’s bed during the period of absence.
  4. the term of absence at camp plus any other accumulated leave days for the calendar year (not including acute care stays) do not exceed 73 days per calendar year.

The bed hold will terminate and discharge status will take effect under the following circumstances: a) if a patient dies while at camp, the bed hold terminates on the day of death (discharged date is the day of death); b) if a patient is admitted to an acute care hospital from camp, the bed hold terminates on the day of departure from camp; c) if the patient leaves camp and does not return to the skilled nursing facility, the bed hold terminates on the day of departure from camp.

Long Term Care Clinical Management

HPSM’s Clinical Management program systematically manages the provision and continuous improvement in the quality and care of service provided to all HPSM members. Measures of quality care and service include the following: access to care, appropriateness of care, process of caring, health outcomes, and member and provider satisfaction. The clinical management activities as related to members residing in long term care facilities comply with all state and federal requirements as specified in the contract between the state and HPSM. The clinical management program focuses on evaluation and improvement of the quality of member care in all settings or levels of care and with primary care and specialty physicians. HPSM is not responsible for any facility oversight as currently carried out by the California Department of Licensing and Certification, or for the California Department of Health Services Field office responsibilities related to the Inspection of Care Adults.

HPSM does assist in the identification and communication of potential quality of care issues with other agencies directly involved in coordination of services for members in long term care facilities including, but not limited to: CCS, Mental Health, and Golden Gate Regional Center. In addition, communication to Licensing and Certification, Medi-Cal Operations Division and the long ter care facility Ombudsman Office for potential quality of care issues may be a part of the QAI activities as indicated.

Plan of Care

Patient Requirements

Skilled nursing and intermediate care facilities must include written Plans of Care in each patient’s medical record.

Individual written plans are required by Title 42, Code of Federal Regulations (CFR) to be approved and signed by a physician. They should include:

  • diagnosis, symptoms, complaints, and complications.
  • description of individual’s functional level.
  • objectives.
  • orders for medication, treatments, restorative and rehabilitative services, activities, therapies, social services, diet, and special procedures.
  • plans for continuing care.
  • plans for discharge.

Skilled Nursing Facility Written Plan of Care

Before admission of a patient to a skilled nursing facility or before authorization for payment, the attending physician must establish a written Plan of Care for each applicant or recipient in a skilled nursing facility. The Plan of Care must include: a) diagnoses, symptoms, complaints, and complications indicating the need for admission; b) a description of the functional level of the individual; c) objectives; d) any orders for medications, treatments, restorative and rehabilitative services, activities, therapies, social services, diet, and special procedures recommended for the health and safety of the patient; e) plans for continuing care, including review and modification to the Plan of Care; f) plans for discharge.

The attending or staff physician and other personnel involved in the recipient’s care must review and sign each Plan of Care at least every 60 days.

Intermediate Care Facility Written Plan of Care

Before admission of a patient to an intermediate care facility or before authorization for payment, a physician or staff physician must establish a written Plan of Care for each applicant or recipient.

The Plan of Care must include:

  • Diagnoses, symptoms, complaints, and complications indicating the need for admission.
  • A description of the functional level of the individual.
  • Objectives.
  • Any orders for: medications, treatments, restorative or rehabilitative services, activities, therapies, social services, diet, and special procedures designed to meet the objective of the Plan of Care.
  • Plans for continuing care, including review and modification of the Plan of Care and plans for discharge. The team must review and sign each Plan of Care at least every 90 days.

Programs for Children, Minors, and Young Adults

Child Health and Disability Program (CHDP)

The CHDP program provides complete health assessments for the early detection and prevention of disease and disabilities for low-income children and youth. A health assessment consists of a health history, physical examination, developmental assessment, nutritional assessment, dental assessment, vision and hearing tests, a tuberculin test, laboratory tests, immunizations, health education/anticipatory guidance, and referral for any needed diagnosis and treatment.

HPSM is responsible for the processing and reimbursement of the PM 160 claims for all HPSM eligible Medi-Cal members. Providers will not submit claims to State CHDP for HPSM eligible Medi-Cal members.

Reimbursement: HPSM reimburses at the current the CHDP maximum allowable rates.

Claims and Claims Processing: Providers must use the PM 160 Information Only (brown form) for HPSM eligible Medi-Cal members. Providers will continue using the PM 160 (green form) for Gateway eligible MediCal beneficiaries and submit these claims to State CHDP for processing.

PM 160 claim information and payments are included in HPSM’s regular Explanation of Payment (EOP). During claims processing, PM 160 claim codes are converted to their corresponding CPT codes and shown on the EOP service lines. PM 160 claim services lines are identified with Explanation Code CH “CHDP Claim – Paid at Maximum Allowable”

Mail completed PM 160 Information Only (brown forms) to:

Health Plan of San Mateo
Attn: Claims Department
801 Gateway Boulevard, Suite 100
South San Francisco, California 94080

Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT)

EPSDT is codified in federal law and creates a benefit that provides a comprehensive array of prevention, diagnostic, and treatment services for individuals under the age of 21 who are enrolled in Medi-Cal. The EPSDT benefit is more robust than the Medicaid benefit for adults and is designed to assure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. The goal of EPSDT is to assure that individual children get the health care they need when they need it—the right care to the right child at the right time in the right setting.

HPSM may not impose service limitations other than medical necessity. Medical necessity for children is defined as necessary health care, diagnostic, treatment, and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether such services are covered under the plan. The determination of whether a service is medically necessary for an individual child must be made on a case-by-case basis, taking into account the particular needs of the child. Since medical necessity decisions are individualized, flat limits or hard limits based on a monetary cap or budgetary constraints are not consistent with EPSDT requirements. Additional services must be provided if determined to be medically necessary for an individual child. HPSM must provide case management and targeted case management.

HPSM has a responsibility to provide health education, including anticipatory guidance, to members under age 21 and to their parents or guardians to effectively use those resources, including screenings and treatment. HPSM must conduct outreach to ensure providers are trained and adhere to Bright Futures guidance.

Providers are required to refer Members to appropriate diagnostic and treatment services following either a preventative screening or other visit that identifies the need for follow-up.

EPSDT covers:

  • Early and periodic screening, diagnostic, and treatment (EPSDT) services.
  • Well-child visits which are a comprehensive set of preventive, screening, diagnostic, and treatment services.
  • HPSM will make appointments and provide transportation to help children get the care they need.
  • Preventive care can be regular health check-ups and screenings to help find problems early. Regular check-ups aid in identifying any problems with medical, dental, vision, hearing, mental health, and any substance use disorders. HPSM covers screening services any time there is a need for them, even if it is not during the regular check-up. Preventive care can also include shots; HPSM must make sure that all children enrolled get needed shots at the time of any health care visit.
    • Screening: (i) comprehensive health and development history (inc. assessment of physical and mental health development); (ii) a comprehensive unclothed exam; (iii) appropriate immunizations according to age and health history; (iv) lab test (including BLL); (v) health education (inc. anticipatory guidance).
    • Screening services must identify developmental issues as early as possible.
  • When a problem is found during a check-up or screening, HPSM covers the care that is medically necessary to correct or help any physical or mental health issues. These services are at no cost to the member and include:
    • Doctor, nurse practitioner, and hospital care.
    • Shots to keep the member healthy.
    • Physical, speech/language, and occupational therapies.
    • Home health services, which could be medical equipment, supplies, and appliances.
    • Treatment for vision and hearing, which could be eyeglasses and hearing aids.
    • Behavioral Health Treatment for autism spectrum disorders and other developmental disabilities.
    • Case management, targeted case management, and health education.
    • Reconstructive surgery, which is surgery to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to improve function or create a normal appearance.
  • If the care is medically necessary and HPSM is not responsible for paying for the care, then HPSM will coordinate care to help members get the right care they need. These services include:
    • Treatment and rehabilitative services for mental health and substance use disorders.
    • Treatment for dental issues, which could be orthodontics.
    • Private duty nursing services.

Complex Care Management

Complex care management uses proactive care management principles. High risk members are identified through a predictive model and health risk assessment and other screening tools. Complex/high risk care management programs focus on providing well-coordinated community-based services, including limiting gaps in care between inpatient and outpatient and community-based services. The framework of the care management programs addresses the complexity of the healthcare system and the difficulty our member’s encounter navigating the health care system- Limited ability to access services negatively affects health status. Goals of our care management programs include a) improving quality of care, b) improving member satisfaction and c) promoting the provision of medically appropriate care through a multidisciplinary, comprehensive approach in a cost-effective manner. For our dually eligible population, Care Advantage, each member receives a health risk screening assessment annually. In addition to the member’s subjective health risk assessment screening tool, a comprehensive assessment is performed on high risk medically complex members. The integration of the comprehensive assessment with the health risk assessment screening tool serves as a basis in development of individualized care plans. Individualized care coordination interventions are documented in a relational database that fosters centralized information and standardization. Care management interventions are developed in conjunction with the member and include a point of contact at the plan responsible for communications with the member. The health risk assessment screening is communicated with the member’s primary care physician. Collaboration and coordination of care with the primary care physician is an integral component of the care management program.

Complex Care Management/Care Coordination/Integrated Care Management Activities include the following:

Comprehensive health risk assessments are performed for each Care Advantage member and high risk Medi- Cal members. This tool is the foundation of the case management process. Assessment and data gathering includes but is not limited to member demographics, primary care physician and specialty physician care information, living status, hospitalization and ED utilization, a review of physiological health systems, past medical history, a medication history and medication regimen, medication therapy management eligibility, social/emotional status, functional status/disability rating, activities of daily living assessment, exercise assessment, fall risk, community resource utilization and assessment, and primary care giver assessment, durable medical equipment ( DME) and medical supply assessment and a needs assessment summary.

The clinical history documents the members’ health status, clinical history, including disease onset, key events such as acute phases and inpatient stays, treatment history and current and past medication.

Activities of daily living evaluate the members’ functional status related eating, bathing, walking, toileting, and transferring.

Mental health status evaluates the members’ mental health status, including psychosocial factors and cognitive functions such as ability to communicate, understand instructions and process information about their illness.

  • Cultural and linguistic needs include an assessment of cultural and linguistic needs, preference or limitations.

  • Caregiver resources are evaluated to assess family involvement in the care plan and the caregiver potential for burn-out.

  • Life planning assessment addresses life planning issues such as living wills/ advance directives/ durable power of attorney.

  • A benefit assessment is also conducted.

  • Individualized care plans are developed from the findings and analysis of the comprehensive health risk assessments.

In-Home Physician Program Through HomeAdvantage

The In-Home Physician program is a system of care that provides 24/7 access to in-home physician visits for the plan’s most medically vulnerable and complex members. This program supports proactive cost management and enhances medical care by treatment through a home delivery system by optimizing care in the home. The services that In-Home Physician program provides include:

  • 24/7 patient access to a visiting physician.
  • Regularly scheduled in- home and facility visits and anytime as needed.
  • Coordinated care with primary care physicians, specialists, and the plan’s nurse Care Manager.
  • Clinical and pharmacy management.
  • Education to the patient about their medical conditions and anticipated outcomes.

Care Transitions

The plan also incorporates a care transition model in the Care and Transition Coordination program. The intent of the care transition model is to improve health care outcomes and reduce re-hospitalization risk when members encounter a care transition. Members experiencing a care transition from the home to an acute care setting or to a skilled nursing facility are identified and followed by the nurse case manager and a care transitions coach through the continuum of care. The nurse case manager serves as a point of contact to the member and the member’s health care team. For each care transition, the nurse case manager also initiates communication to the member’s primary care physician. The primary goal of the nurse case manager coach is to support the member and the member’s healthcare team to ensure appropriate communication and benefit coordination occurs in a timely manner.

Medication Therapy Management (MTM)

Medication Therapy Management is the analytical, consultative, educational, and monitoring services provided by pharmacists to Care Advantage members in order to facilitate the achievement of positive therapeutic and economic results from medication therapy. MTM services allow pharmacists to work collaboratively with physicians and other prescribers to enhance quality of care, improve medication compliance, address medication needs, and provide healthcare to plan members in a cost-effective manner.

HPSM contracts with the vendor, SinfoniaRx, to administer MTM services. MTM services include comprehensive medication review (CMR), prescriber communications, member compliance consultations, and member education and monitoring.

Comprehensive medication review is performed annually. During the CMR, a pharmacist will review the member’s prescription and nonprescription medication, vitamins, minerals, herbal products, and dietary supplements for potential interactions. As part of the review, a master medication list will be provided to the member to bring to future office visits.

Prescriber communications assist physicians and other prescribers to coordinate care and resolve potential medication- related complications. These communications may include a phone call or fax to the prescriber’s office with information and/or recommendations concerning a member’s drug therapy regimen.

Member compliance consultations assist members with compliance issues. MTM pharmacists monitor plan members for compliance with prescribed medications. When an overuse, underused, or administration issue is identified, the pharmacist will educate the member on the importance of compliance and monitor the member to ensure that compliance improves.

Member education and monitoring is performed when a member is prescribed a new medication therapy or experiences a change in therapy. MTM pharmacists monitor the member for improvement in reportable symptoms, the occurrence of the side effects and compliance with therapy.

Indian Health Care Providers (IHCPs) Rights and Protections

Existing rights and protections for IHCPs, on the topics of enrollment, contracting, credentialing and site review, and claims payment are described here.

Effective January 1, 2024, HPSM is required to have an identified tribal liaison dedicated to working with each contracted and non-contracted IHCP in its service area. The tribal liaison is responsible for coordinating referrals and payment for services provided to American Indian members who are qualified to receive services from an IHCP. IHCPs can direct questions to the Tribal Liaison at

The role and responsibilities of the tribal liaison include, but are not limited to the following:

  • Providing information to IHCPs regarding enrollment and disenrollment of American Indian members.
  • Coordinating care with in- and out-of-network IHCPs for American Indian members.
  • Ensuring access to care with in- and out-of-network IHCPs for American Indian members.
  • Providing assistance to IHCPs and American Indian members with accessing appropriate transportation given logistical and geographical barriers unique to tribal communities.
  • Providing case management for American Indian members that involves in- and out-of-network IHCPs.
  • Assisting IHCPs with provider relations services, claims and payment assistance and resolution, and member services.
  • Providing support in obtaining grievance, appeal, and State Hearing services to IHCPs in cases that impact American Indian members.
  • Providing benefits and services navigation and coordination, such as those for foster care, Community Based Adult Services, Enhanced Care Management, Community Supports, behavioral health, health education, home and community based services, California Children’s Services (CCS), etc. This is to ensure IHCPs provide full-spectrum services to American Indian Members.
  • Assisting internal liaisons in instances that involve IHCPs and/or American Indian Members and the other liaison’s respective services and program, in particular the foster care liaison; as well as the liaisons for Long-Term Services and Supports, transportation, California Children’s Services, Regional Center, dental, and IHSS.
  • Providing assistance to IHCPs regarding Medi-Cal program provider enrollment and HPSM contracting, credentialing, and Facility Site Reviews.

The tribal liaison, including new tribal liaison staff, will attest to the completion of and document completion of the following trainings:

  • Cultural humility training from the California Governor’s Office of the Tribal Advisor.
  • Overview of trauma-informed care and historical trauma training from the Indian Health Service (IHS).
  • Other relevant trainings as they are developed and noted by DHCS.

DHCS encourages tribal liaisons to commit to the following activities to enhance relationships between HPSM, IHCPs, and American Indian members:

  • Providing assistance to the Member Services department in situations involving American Indian members.
  • Representing HPSM and providing assistance to subcontractors to address inquiries and/or instances involving American Indian members.
  • Participating in the HPSM Community Advisory Committee and other HPSM committees that potentially impact American Indian members.
  • Attending and participating in tribal consultations involving tribes within the service area.
  • Attending and participating in DHCS’ Tribal and Designees of Indian Health Programs Quarterly Meeting, and other relevant meetings.
  • Developing tribal specific outreach and educational materials.
  • Hosting marketing events and developing marketing materials focused on tribal health as permitted.
  • Collaborating with other managed care plans' tribal liaisons to discuss best practices, lessons learned, and sharing of information and resources.
  • Collaborating with local tribal communities on the development of regional and culturally appropriate trainings for HPSM staff.
  • Having knowledge and consideration of Indigenous Determinants of Health when determining quality metrics and data reporting.

Terminated Providers

HPSM has a mechanism to continue appropriate and timely care for members whose physicians are terminating from the network. This process includes a 90-day notification from the practitioner of the intent to terminate. Members under current care and those with approved prior authorizations, not yet utilized, are identified so that their care can be managed and coordinated with the receiving physicians. Members, such as those undergoing cancer treatments of chemotherapy or radiation therapy, dialysis-dependent members, those awaiting transplants, late-term pregnancies, pending surgeries, acute rehabilitation, and any other members that might have their ongoing care negatively impacted by the termination of the group are identified. When members are identified as possibly benefiting from coordination of care both within and outside of the network, the case is referred to complex care management team for further interventions. Complex care management actively engages in activity that monitors and assesses continuity and coordination of clinical care. Complex care management works closely with the member, physicians and any other associated ancillary providers involved in the case, to provide timely, quality-based care meeting the needs of the individual member.

Monitoring and Reviewing

Monitoring for Consistent Review Criteria

The Health Services Utilization Review Manager and Care Coordination Manager perform ongoing monitoring of UM nurse reviewer application of criteria/guidelines to:

  • Measure the reviewers’ comprehension of the review criteria and guideline application process.
  • Ensure accurate and consistent application of the criteria among staff reviewers, and ensure criteria and guidelines are utilized per policy/ procedure.
  • Ensure a peer review process for inter-rater reliability.

The Health Services staff is responsible for identification of potential or actual quality of care issues, and cases of over- or under-utilization of healthcare services for HPSM members during all components of review and authorization.

Monitoring for Over and Under Utilization

To review appropriateness of care provided to members, HPSM tracks and trends various data elements to determine over- and/or under- utilization patterns. The industry benchmark rates are used as guidelines for comparison. Some of the elements reviewed include:

  • Hospital admits/1,000.
  • Re-admissions.
  • Pharmacy utilization.
  • Bed days/1,000, using HPSM performance standards.
  • Emergency room visits.
  • Encounters per enrollee per year.
  • Behavioral Health inpatient admissions.
  • Denials.
  • Frequency of selected procedures, as determined by utilization patterns.
  • Medi-Cal Medical Directors Utilization Reports.
  • Industry Collaborative Effort Utilization Reports.
  • Cultural/Linguistic reports that reflect barriers for access to care or delivery of care.

HPSM enacts actions to improve performance as a result of these clinical data analysis, and feedback is provided to both entities and individual practitioners so that corrective actions can be taken. HPSM continues to monitor for compliance with corrective action plans and improvements in the care delivery process.

Review Criteria, Guidelines, and Standards

Standards, criteria, and guidelines are the foundation of an effective Utilization Management Program. They offer the licensed UM staff explicit and objective "decision support tools," which are utilized to assist during evaluation of individual cases to determine the following:

  • If services are medically necessary.
  • If services are rendered at the appropriate level of care.
  • Quality of care meets professionally recognized industry standards.
  • Consistency of UM decisions.

The following standards, criteria, and guidelines are utilized by the Health Services UM review staff and Medical Director as resources during the decision-making process:

  • Medical necessity review criteria and guidelines.
  • Length of stay criteria and guidelines.
  • Clinical practice guidelines.
  • Policies and procedures.

Decision Support Tools

The appropriate use of criteria and guidelines require strong clinical assessment skills, sound professional medical judgment and application of individual case information and local geographical practice patterns.

Licensed nursing review staff applies professional judgment during all phases of decision-making regarding HPSM members.

"Decision Support Tools" are intended for use by qualified licensed nursing review staff as references, resources, screening criteria and guidelines with respect to the decisions regarding medical necessity of healthcare services, and not as a substitute for important professional judgment.

The HPSM Medical Director evaluates cases that do not meet review criteria/guidelines and is responsible for authorization/ denial determinations.

HPSM's Health Services UM review staff clearly document the Review Criteria/Guidelines utilized to assist with authorization decisions. If a provider should question a medical necessity/ appropriateness

determination made, any criteria, standards, or guidelines applied to the individual case supporting the determination is provided to the provider for reference.

The following approved department "Decision Support Tools" have been implemented and are evaluated and updated at least annually:

Criteria and Guidelines

Approved HPSM Guidelines shall be used for all medical necessity determinations. HPSM uses the following criteria sets: Medi-Cal Manual of Criteria, published by the State of California, American Academy of Pediatric Guidelines (AAP), Milliman Care Guidelines, Medicare Coverage manual and the HPSM Medical Policy and Medi-Cal Benefits Guidelines (Medi-Cal Provider manuals- Allied Health, Inpatient/Outpatient, Medical, Vision, Pharmacy).

Due to the dynamic state of medical/healthcare practices, each medical decision must be case-specific based on current medical knowledge and practice, regardless of available practice guidelines. Listed criteria in fields other than primary care such as OB/GYN, surgery, etc. are primarily appended for guidance concerning medical care of the condition or the need for the referral.

Medi-Cal Manual

The State of California publishes Medi-Cal Manual of Criteria, which is the basis for Medi-Cal benefit interpretation and used as a UM guideline.

Milliman Care Guidelines Criteria

Milliman Care Guidelines are developed by generalist and specialist physicians representing a national panel from academic as well as community-based practice, both within and outside the managed care industry.

Milliman’s clinical staff of physicians, nurses, and other healthcare professionals create initial drafts of the criteria based on input from consultants, as well as an exhaustive review of existing guidelines and medical literature. Physicians and other providers from all disciplines relevant to the subject then review, revise, and re-review these versions in an iterative, consensus-building process (a modification of the Delphi method). Criteria acknowledge controversial areas where agreement cannot be reached and provide a rationale for the stance that has been chosen. Detailed notes and literature references provide the clinical basis for decisions. The criteria therefore provide a synthesis of evidence-based data, literature-supported medicine, and national consensus. Milliman criteria enable health plans and providers to capture data about the intervention requested and the rationale for each request. The criteria also provide a clinical reference for managing the dialogue between provider and reviewer, provider and payer, and provider and patient. Milliman criteria support an explicit, clinical rationale for care decisions.

Milliman guidelines update cycles are done at a minimum on an annual basis. Milliman states that update reviews include development of new procedures, new technology, requests from clients, criteria incorporating high frequency, high risk, high visibility and high variation, literature review and analysis, new clinical practice. (Milliman, 2007)

Utilization Management Appeals Process

An organization determination is any decision made by or on behalf of HPSM regarding the payment or provision of a service a member believes he or she is entitled to receive. An organizational determination is made in response to a Prior Authorization Request or a request for Prior Authorization submitted by a provider and may include approval, denial, deferral, or modification of the request. HPSM has a comprehensive review system to address matters when members or providers (on behalf of members for services yet to be provided) wish to exercise their rights to appeal an organizational determination that denied, deferred, or modified a request for services.

The administration of HPSM’s reconsideration of an organization determination and appeals process is the responsibility of the Grievance and Appeals Coordinator under the direct supervision of the Grievance and Appeals Manager. All investigation efforts are geared to protect the enrollee’s privacy and confidentiality and to achieve rapid resolution.


Due to the nature of routine UM operations, HPSM has implemented policies and procedures to protect and ensure confidential and privileged medical record information. Upon employment, all HPSM employees, including contracted professionals who have access to confidential or member information sign a written statement delineating responsibility for maintaining confidentiality.

Both the HPSM UM staff voice mail phone message line for utilization review information and the computer network system are controlled by a secured password system, accessible only by the individual employee.

The facsimile machines used for utilization review purposes are located within the department to assure monitoring of confidential medical record information by HPSM UM staff. HPSM has implemented Health Information Portability and Accessibility Policies and Procedures to guide the organization in HIPAA compliance. All records and proceedings of the UM Committee related to member or provider specific information are confidential and are subject to applicable law regarding confidentiality of medical and peer review information, including Welfare and Institutions Code section 14087.58.

Conflict of Interest

HPSM maintains a conflict of interest policy to ensure that conflict of interest is avoided by staff and members of Committees. This policy precludes using proprietary or confidential HPSM information for personal gain, or the gain of others, as well as a direct or indirect financial interest on or relationship with a current or potential provider, supplier, or member; except when it is determined that the financial interest does not create a conflict.

Fiscal and clinical interests are separated. HPSM and its delegates do not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service care. Financial incentives for UM decision makers do not encourage decisions that result in under-utilization.

Staff Orientation, Training and Education

HPSM seeks to recruit highly qualified individuals with extensive experience and expertise in UM for staff positions.

Qualifications and educational requirements are delineated in the position descriptions of the respective position.

Each new employee is provided an intensive hands-on training and orientation program with a staff preceptor. The following topics are covered during the program as applicable to specific job description:

  • HPSM New Employee Orientation.
  • Use of technical equipment (phones, computers, printers, facsimile machines, etc.).
  • Utilization Management Program, policies/procedures, etc.
  • Care Coordination/Integrated Care Management Model of Care, policies, and procedures.
  • MIS data entry.
  • Application of review criteria/guidelines.
  • Appeal Process.
  • Orientation to specific programs of each delegated entity.

HPSM encourages and supports continuing education and training for employees, which increases competency in present jobs and/or prepares employee for career advancement within the HPSM. Each year, a specific budget is set for continuing education employees.

Licensed nursing staff is monitored for appropriate application of Review Criteria/ Guidelines, processing referrals/service authorizations, and inter-rater reliability. Training opportunities are addressed immediately as they are identified through regular administration of proficiency. Training, including seminars and workshops, are provided to all UM staff regularly during regularly scheduled meetings and ongoing.

End of Section 7: Utilization Management