Sanfranciscohealthplan Coverage Criteria
Latest Sanfranciscohealthplan coverage criteria updates7
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-20Durable Medical Equipment (DME) Coverage CriteriaDefines San Francisco Health Plan (SFHP) coverage, authorization, and operational rules for durable medical equipment for members across specified SFHP lines of business, including Medi-Cal and certain HMO products.All sanfranciscohealthplan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-06-01Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Private Duty Nursing (PDN) Medical Necessity CriteriaGoverns SFHP prior authorization and medical-necessity determinations for EPSDT private duty nursing services for Medi-Cal beneficiaries under age 21, using the Private Duty Nursing Acuity Grid to determine authorized shift-care hours.All sanfranciscohealthplan updates
- Coverage CriteriaClinical/Medical PolicyAbaloparatide (Tymlos) — Prior Authorization and Coverage CriteriaDefines prior authorization and coverage restrictions for abaloparatide (TYMLOS) for San Francisco Health Plan members, including a 24-month cumulative parathyroid-class treatment limit, prescriber and documentation requirements where specified, and typical authorization durations.All sanfranciscohealthplan updates
- Coverage CriteriaClinical/Medical PolicyAntiulcer agents — formulary step edits and prior-claim requirements (coverage criteria)Rules governing formulary step edits and prior-claim requirements for various oral antiulcer and related products; affects providers prescribing or dispensing the listed products to San Francisco Health Plan members.All sanfranciscohealthplan updates
- Coverage CriteriaClinical/Medical PolicyControlled substances opioid therapy agreement — Coverage criteriaDefines expectations, responsibilities, monitoring, and grounds for discontinuation when prescribing controlled opioid analgesics to San Francisco Health Plan patients in primary care; affects patients receiving scheduled (controlled) opioid medications and their prescribing providers.All sanfranciscohealthplan updates
- Coverage CriteriaClinical/Medical PolicySensitive Services / Minors' Rights — Coverage CriteriaPolicy governing minors' consent to sensitive medical services (pregnancy-related care, family planning, STI-related care, and care for emancipated/financially independent minors) at San Francisco Health Plan-contracted sites; directed at clinical staff, site management, and PCP site reviewers to ensure compliance with California Family Code and DHCS requirements.All sanfranciscohealthplan updates
- Coverage CriteriaClinical/Medical PolicyUtilization Management Clinical CriteriaDefines 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.All sanfranciscohealthplan updates
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Tool Description
Search Sanfranciscohealthplan coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
Coverage Criteria by Payer
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Coverage policies are updated every day. Follow payer coverage policy updates in the live policy feed, or browse all CPT, HCPCS and DRG billing codes.
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