Medi‑Cal prior authorization rules

Medi‑Cal outpatient abortions: members may self‑refer to any provider for outpatient abortion services without prior authorization, and the provider need not be contracted with SFHP. Inpatient abortions: require prior authorization and must be performed within the member's medical group/network; if unavailable within the member's medical group/network, SFHP will approve authorization to another SFHP network facility and, if necessary, to an out‑of‑plan facility.

• Outpatient abortions for Medi‑Cal do not require prior authorization and providers need not be contracted with SFHP. [[citation provided above]]
• Inpatient abortions require prior authorization and should be performed within the member's medical group/network; SFHP will authorize transfer to another SFHP network facility or out‑of‑plan facility if service is unavailable.

Healthy Workers HMO prior authorization rules

Healthy Workers HMO outpatient abortions do not require prior authorization but must be provided within the member's medical group; if services are not available in the medical group, SFHP will approve out‑of‑medical‑group and, if necessary, out‑of‑network authorization. Inpatient abortions require prior authorization and must be performed within the member's medical group; if unavailable, SFHP will approve authorization within the SFHP network.

• Outpatient: no prior authorization required, must stay within member's medical group unless unavailable (then out‑of‑group or out‑of‑network approved).
• Inpatient: prior authorization required and should be within the medical group; SFHP will approve within network if not available in the medical group.

General prior authorization statement

SFHP does not require prior authorization for outpatient abortion services generally; however, inpatient abortion services require prior authorization.

• Outpatient abortions: no prior authorization required across SFHP lines of business.
• Inpatient abortions: prior authorization is required.

Mifepristone prescribing and reporting

Prescribing providers of mifepristone must meet federal qualifications and follow the FDA‑approved treatment regimen and reporting requirements; they must notify the manufacturer in writing of ongoing pregnancy after treatment and report serious adverse events (hospitalization, transfusion, or other serious events) identifying the member only by package serial number to protect confidentiality.

• Provider qualifications include ability to assess pregnancy duration, diagnose ectopic pregnancy, and provide or arrange immediate intervention for complications.
• Emphasize need for timely follow‑up to confirm complete termination and absence of complications.
• Report ongoing pregnancy in writing to the manufacturer and report serious events (hospitalization, transfusion, etc.) using package serial number for member identification.