Important Authorizations Announcement
PG&E has begun their planned power-outage in multiple Bay Area cities as of this morning. HPSM is committed to ensuring members continue to receive necessary services during this period by working closely with our provider community.
HPSM will continue to review items that require authorization for medical necessity. In order to not delay necessary care we will take these circumstances into special consideration for items that normally require prior authorization. Please do not hesitate
to contact HPSM about any special authorization needs for items impacted by this power outage. Read more
Before providing treatment or prescribing medication for an HPSM member, you may need to submit a Prior Authorization Request Form to ensure that it is covered. HPSM expects providers to obtain authorization for all services requiring prior authorization before they provide the
service. Exceptions are made for urgent and emergency services.
Prior Authorization List
IMPORTANT NOTE: Prior authorization is based on medical necessity and is 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.
Only valid codes will be reviewed. Please refer to CMS/MC guidelines to verify validity. Codes are updated regularly and posted below.
It is expected that all services requiring prior authorization must be authorized before providing the service, with the exception of services that are necessary on an emergent or truly urgent basis. For authorization requests submitted prior to the date of service, expect a response from HPSM within:
- 72 hours for urgent or expedited authorization requests
- Five business days for routine authorization requests
Before submitting a request, search HPSM's Prior Authorization List by CPT code or service name to see if you need to get prior authorization:
Download the PAR List: Prior Authorization Required List
To use spreadsheet functions, download the Excel file: Prior Authorization Required List
List last Updated 10/01/2019
Prior Authorization List Changes
HPSM periodically updates our list of codes requiring prior authorization to reflect current clinical guidelines. You can review these changes or archived lists on the PAR List Changes page.
Unique Authorization Requirements
Unique authorization rules apply for certain types of healthcare services or products. Please see our page on Specialty Provider Authorizations for detail on:
Frequently Asked Questions
Our PAR list is typically updated quarterly, with the caveat that regulatory changes may require us to update it more frequently. This is a new process that we implemented in the spring of 2018 in response to provider feedback about the frequency of changes. Please check our website regularly, and make sure your email and fax information is up to date to ensure you’re receiving these notices.
HPSM has developed a new Provider Portal that is currently being tested by a small group of providers before it is deployed to the full network. This portal will be rolled out to HPSM-contracted providers in waves starting in the summer of 2019. The new portal allows providers to check the status of authorization requests online for the first time. You can access the current version of the Provider Portal here.
An HPSM-contracted PCP may ask you to provide service for a patient. If you agree, you must get prior authorization before providing any non-emergency services for HPSM members. The PCP will typically request your services by submitting a Referral Authorization Form (RAF) to HPSM. If HPSM approves the PCP’s request, an authorized RAF will be faxed to your office. Once you receive this, contact the member to schedule an appointment. If you’re interested in contracting with HPSM, please reach out to email@example.com.