Prior Authorization

For some types of care, your PCP or specialist will need to ask HPSM for permission before you get the care. This is called asking for prior authorization, prior approval, or pre-approval. It means that HPSM must make sure that the care is medically necessary or needed.

Care is medically necessary if it is reasonable and necessary to protect your life, keeps you from becoming seriously ill or disabled, or alleviates severe pain.

IMPORTANT NOTE: Prior authorization is based on medical necessity and not a guarantee of coverage or eligibility. If a service is not included on this list, the service does not require prior authorization. However, this does not mean it is a covered benefit.

Please talk with your provider to find out if a service is a covered benefit or call Member Services at 1-800-750-4776 or 650-616-2133.

The following services always need pre-approval, even if you receive them from a provider in the HPSM network:

  • Hospitalization, including long term care
  • Services out of the HPSM service area
  • Outpatient surgery
  • Long-term therapy
  • Specialized treatments
  • Specialized radiology procedures such as a CT scan or an MRI

Pre-approval for Emergency Care

You never need pre-approval for emergency care, even if it is out of network. This includes having a baby.

If you are not sure whether you need prior authorization for a treatment, please talk to your primary care provider (PCP). You can find your PCP's phone number on your HPSM member I.D. card.

You can also look at HPSM's Prior Authorization Required List to determine whether the service requires prior authorization. Please note that a given treatment can have multiple procedure codes. Please talk to your provider if you do not know the procedure code for the treatment you are requesting.

Decision timeframes

Under Health and Safety Code Section 1367.01(h)(2), HPSM will decide routine pre-approvals within 5 working days of when HPSM gets the information reasonably needed to decide.

For requests in which a provider indicates or HPSM determines that following the standard timeframe could seriously jeopardize your life or health or ability to attain, maintain, or regain maximum function, HPSM will make an expedited (fast) authorization decision. HPSM will give notice as quickly as your health condition requires and no later than 72 hours after receiving the request for services.

Pre-approval requests are reviewed by clinical/medical staff, such as doctors, nurses and pharmacists. Reviewers use current clinical guidelines to meet state and national standards to decide if the request is medically necessary.

HPSM does not pay the reviewers to deny coverage or services. If HPSM does not approve the request, HPSM will send you a Notice of Action (NOA) letter. The NOA letter will tell you how to file an appeal if you do not agree with the decision.

HPSM will contact you and your provider if HPSM needs more information or more time to review your request.

Referrals

Your PCP will give you a referral to send you to a specialist if you need one. A specialist is a doctor who has extra education in one area of medicine. Your PCP will work with you to choose a specialist. Your PCP’s office can help you set up a time to see the specialist.

Other services that may require a referral include in-office procedures, X-rays, lab work and specialty services. 

Your PCP may give you a form to take to the specialist. The specialist will fill out the form and send it back to your PCP. The specialist will treat you for as long as he or she thinks you need treatment.

If you have a health problem that needs special medical care for a long time, you may need a standing referral. This means you can see the same specialist more than once without getting a referral each time.

If you have trouble getting a standing referral or want a copy of the HPSM referral policy, call 1-800-750-4776 (TTY 1-800-735-2929 or dial 7-1-1).

You do not need a referral for:

  • PCP visits
  • Ob/Gyn visits
  • Urgent or emergency care visits
  • Family planning (to learn more, call California Family Planning Information and Referral Service at 1-800-942-1054)
  • HIV testing and counseling (only minors 12 years or older)
  • Treatment for sexually transmitted infections (only minors 12 years or older)
  • Acupuncture
  • Chiropractic services
  • Podiatry services

Minors also do not need a referral for:

  • Outpatient mental health for:
    • Sexual or physical abuse
    • When you may hurt yourself or others
  • Pregnancy care
  • Sexual assault care
  • Drug and alcohol abuse treatment