Prior Authorization
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Defines SFHP's prior authorization processes, requirements, submission and monitoring procedures for providers and delegated groups across SFHP managed care lines of business.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria
Prior Authorization Coverage Criteria
Covered when the following authorization requirements and conditions are met:
Exemptions (no prior authorization required)
- Emergency and urgent care services.
- Special arrangements: family planning, sexually transmitted infection services, and HIV testing.
- Basic prenatal care, routine and preventive care provided by OB/GYNs and family medicine providers, and certain preventive services and specialty office visits when received within the member's medical group/network.
Approval periods
- Standard approval period for services: 1 year.
- Approval period for elective surgeries: 3 months.
Required Codes and Submission Elements
| CPT/HCPCS | At least one valid service code required for processing |
| ICD-10 | At least one valid diagnosis code required for processing |
| Member's first and last name | Member identification required for processing |
| Member's date of birth | Member identification required for processing |
Provider Submission, Documentation, and Notifications
Submission methods and timing
Submit all non-emergent prior authorization requests at least 5 business days prior to the anticipated service date. Use the provider portal (preferred) to access real-time authorization rules and decisions; fax, email, telephone, or mail are accepted alternative submission methods. Retrospective (post-service) requests must be submitted separately per CO-22.
- Provider portal is the preferred submission method and provides real-time rules/decisions.
- Alternative methods: fax, email, telephone, or mail.
- Retrospective requests follow CO-22 guidance and are submitted separately.
Documentation and verification responsibilities
Provide sufficient clinical information and documentation to substantiate medical necessity with the prior authorization request, and verify member eligibility and medical group/network assignment prior to delivering services.
- Include relevant recent notes on the member's health history and progress, physical exams, prescriptions, and medical reasons for the requested service.
- Verification of eligibility and network assignment is required to avoid possible denial of reimbursement; approval of authorization does not guarantee payment.
Notification and turnaround
SFHP will notify members and providers of approvals, denials, partial denials, and deferrals within the timeframes defined in CO-22; providers receive notifications by fax and decisions are also viewable on the provider portal.
- Members are notified by mail; CO staff may also notify by phone or other formats per member preferences.
- Modification requests restart the decision timeframe and follow the same timeframes as initial requests.
Services exempt from prior authorization
Prior authorization is not required for emergency care, urgent care, family planning, sexually transmitted infection services, HIV testing, basic prenatal care, and routine preventive services when received within the member's medical group/network.
- These services are excluded from prior authorization regardless of where emergency/urgent care and special arrangements occur.
- Routine preventive and basic prenatal/OB/GYN/family medicine services do not require prior authorization when provided in-network.
Modification of existing authorizations
Providers may request modifications to an existing approved authorization (for types of service, additional units, or date changes) during the authorization period or within 30 days after the service; modification requests must reference the original authorization number and restart the decision timeframe.
- Submit documentation for all change requests via fax and reference the original Authorization Number and the code(s)/details to be modified.
- Date changes are allowed only if the member has not received the service or due to administrative error.
Fax form requirements and form format
Faxed prior authorization requests must use SFHP's Prior Authorization Request Form with all required information typed in; handwritten forms will not be accepted.
- If required information (e.g., member name, DOB, rendering provider/facility, ≥1 diagnosis code, ≥1 service code, units/quantities when appropriate) is missing, the request cannot be processed and the provider will be notified by fax or phone.
Key Definitions
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