Continuity of Care
New Members
New HPSM members can request continuity of care received from a current doctor who is not in HPSM’s network. Continuity of care may be allowed for up to twelve months. Approval for continuity of care depends on the following conditions:
- The new HPSM member must have been seen by the non-contracted provider within the prior twelve months
- The non-contracted provider must agree in writing to accept HPSM’s payment.
If you have HPSM Medi-Cal and Medicare, you can join HPSM’s CareAdvantage plan! Most of the 6,500 providers in the CareAdvantage network also see HPSM Medi-Cal members – so you can probably keep seeing all of your current providers!
If a provider ends their contract with HPSM
If a member’s PCP or specialist terminates their HPSM contract, the member may request coverage for continued care up to 12 months. Approval for extended coverage depends on whether the member is being treated for certain medical conditions. The doctor also needs to agree in writing, with the payment terms in effect before contract termination.
Request continuity of care with an out-of-network doctor
Call Member Services. They will then notify you of HPSM’s decision. If you disagree with a decision to not approve your continuity of care request, contact Member Services and tell them you want HPSM to reconsider its decision.
Prior Authorization Requests (PAR)
Some medical services and medicines such as physician administered drugs (PADs) or enteral nutritional supplements need to be approved by HPSM for your treatment before you receive them. This is called prior authorization of health care services. Your provider needs to request authorization when it is necessary. Not all services and medicines require authorization.
How your provider requests authorization for services
- Your provider completes a form for a service or medicine that requires prior authorization
- HPSM’s clinical staff review the medical necessity of the service requested
- When a request is denied, you and your provider will receive a letter that explains the reason for denial (Notice of Action)
- Some requests are deferred (decision postponed) because HPSM clinical staff need more medical information from your provider to make a decision. When this happens, HPSM sends you a letter to inform you that more information has been requested from your provider
If you disagree with a denial to approve an authorization request, you can contact HPSM Grievance and Appeals.
New address or contact information?
If you move and/or change your contact information (phone number, email), you must tell both HPSM and either the San Mateo County Human Services Agency at 1-800-223-8383 or Social Security Administration at 1-800-772-1213. This will ensure that you continue to get important information about your Medi-Cal coverage status.
To report your new information with HPSM, you can log in to the Member Portal or call the number below if you need assistance.
Member Services
Toll free: 1-800-750-4776
Local: 650-616-2133
TTY: 1-800-735-2929 or dial 7-1-1
Phone hours: Monday–Friday 8:00 a.m. to 6:00 p.m.
Office hours: Monday–Friday 8:00 a.m. to 4:00 p.m.
Email: MemberServicesSupport@hpsm.org
For more information about continuity of care, refer to section 2 of Medi-Cal Member Handbook / Evidence of Coverage. To order a printed Member Handbook, email MemberServicesSupport@hpsm.org or call Member Services.