CurrentsanfranciscohealthplanPolicy CO-57

Utilization Management Clinical Criteria

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Defines SFHP's process and hierarchy for establishing and applying clinical criteria for utilization management across SFHP lines of business, affecting SFHP clinical operations staff, delegated medical groups, providers, and members.

Policy Summary

Payersanfranciscohealthplan

PolicyUtilization Management Clinical Criteria

Policy CodePolicy CO-57

Change TypeNo material change

Effective Date

Last ReviewDec 18, 2025

Next Review DateDec 23, 2025

Key ActionSubmit required clinical documentation and request prior authorization so UM staff can evaluate the member's clinical information against established criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

annualUM criteria review frequency by UMC and QIHEC

90%IRR passing threshold for reviewers

3SFHP lines of business this policy applies to

CO-57Policy identifier

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CurrentsanfranciscohealthplanPolicy CO-57

Utilization Management Clinical Criteria

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Policy Summary

Payersanfranciscohealthplan

PolicyUtilization Management Clinical Criteria

Policy CodePolicy CO-57

Change TypeNo material change

Effective Date

Last ReviewDec 18, 2025

Next Review DateDec 23, 2025

Key ActionSubmit required clinical documentation and request prior authorization so UM staff can evaluate the member's clinical information against established criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

annualUM criteria review frequency by UMC and QIHEC

90%IRR passing threshold for reviewers

3SFHP lines of business this policy applies to

CO-57Policy identifier

Coverage Criteria and Decision Hierarchy

General UM determination logic

Criteria are applied using the following hierarchy and individual clinical information to determine medical necessity and authorization:

Criteria Hierarchy: Apply resources in the following order: (1) State/Federal (Medi-Cal/CMS) criteria including NCDs/LCDs, CFR/CCR, DHCS guidance and related statutes; (2) Evidence-based guidelines (e.g., MCG, WPATH, relevant professional associations); (3) SFHP internally developed and approved criteria; (4) Specialty Practice Criteria; when no external or internal criteria exist, utilize an Independent Review Organization (MRIoA) and specialty physician consultation.

From Procedure I. Criteria Hierarchy

Clinical Information Considerations: Evaluate the member’s clinical information in conjunction with the criteria, including: office and hospital records; history of the presenting problem; physical examination results; diagnostic test results; treatment plans and progress notes; consultations; operative/pathology reports; rehabilitation evaluations; patient characteristics and treating physician statements of medical necessity. Consider individual member factors (age, cultural/linguistic needs, comorbidities, psychosocial needs, home/work environment) and local delivery system characteristics (availability of alternative levels of care, timely access, specialty provider availability, community resources, familial supports, and benefit coverage).

From Procedure II. Application of Criteria

MD escalation: Requests that do not meet medical necessity criteria are referred to an MD for further evaluation; the MD may request additional documentation, obtain external independent specialty review when the scope is outside their expertise (e.g., MRIoA), approve based on clinical judgment and supplemental considerations (such as EPSDT protocols or advanced evidence), or deny for lack of medical necessity. Denials for medical necessity are only made by an MD.

Describes escalation and decision authority from Procedure II.D

Prescription drugs dispensed at a walk-in pharmacy are not a medical benefit and are not within the scope of this policy. This exclusion distinguishes pharmacy-dispensed outpatient medications from medical-benefit services subject to Utilization Management under this policy.

Requests that do not meet the applied medical necessity criteria are referred to a physician for further evaluation; denials for lack of medical necessity are only made by an MD. The reviewing MD may request additional documentation, seek external specialty review, approve based on clinical judgment and supplemental considerations, or issue a denial if the criteria are not met.

Coding and Quality Metrics

Inter-rater reliability passing threshold — 90%

IRR passing threshold90% passing threshold required for both physician and nurse reviewers (reviewers allowed two opportunities to reach threshold)

New staff requirementNew hires must complete IRR testing before conducting unsupervised utilization reviews; passing threshold is 90%

Remediation for failuresReviewers unable to reach 90% are placed on educational corrective action (training, increased review, supervisor feedback, reassessment)

Scope of IRR toolsGender Affirmation, Custodial Care, and EPSDT Private Duty Nursing use an internally developed IRR tool; other services use MCG standard IRR tool

Audit frequencyIRR audits performed at least annually for physicians and nurse reviewers

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization follows the criteria hierarchy

Prior authorization decisions are determined by applying SFHP's criteria hierarchy — State/Federal (Medi‑Cal/CMS) criteria, evidence-based guidelines (e.g., MCG, WPATH, professional associations), SFHP internally developed and approved criteria, then Specialty Practice Criteria — to the member's clinical information; Physician Administered Drugs (PADs)/Medicare Part B drugs are a medical benefit and are subject to these criteria and procedures.

Apply resources in order: State/Federal (NCDs/LCDs/CFR/CCR/DHCS guidance), Evidence-based guidelines, SFHP internal criteria, Specialty Practice Criteria.
PADs/Medicare Part B drugs are medical benefits and are subject to the criteria hierarchy.

Step Therapy

Use MRIoA and specialty consult when no criteria exist

When no applicable external or internally developed criteria exist, SFHP obtains external specialty expertise through its Independent Review Organization (Medical Review Institute of America, MRIoA) and consults the Chief Medical Officer or physician designee to inform authorization decisions.

Definitions

Medical Necessity — Medi‑Cal definition

Medi-Cal definitionReasonable and necessary services to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury.

EPSDT membersFor members eligible for EPSDT services, services are medically necessary when needed to correct or ameliorate defects and physical and mental illnesses or conditions.

PurposeDefines the standard used to determine when services qualify as medically necessary under Medi‑Cal.

Background and Scope

This policy defines how SFHP staff and delegated UM entities apply medical necessity criteria to manage covered benefits using a hierarchical approach. Resources are applied in order: (1) State and Federal guidance and regulations (e.g., Medi‑Cal/CMS); (2) evidence‑based guidelines (such as MCG and relevant professional associations); (3) SFHP internally developed and approved criteria; and (4) specialty practice criteria. When no applicable external or internal criteria exist, SFHP escalates decisions to an Independent Review Organization and specialty physician consultation. In applying these resources, reviewers evaluate relevant individual clinical information — including office and hospital records, history, exam findings, diagnostic test results, treatment plans, progress notes, consultations, operative/pathology reports, rehabilitation evaluations, patient characteristics, and treating physician statements — and consider patient‑specific factors (age, comorbidities, cultural/linguistic needs, psychosocial needs) and local delivery system characteristics to determine medical necessity and authorization.