Prior Authorization for Referrals

HPSM-contracted specialists without prior authorization
Specialists outside of HPSM’s network if an appropriate in-network specialist is not available

Identify and contact the specialist provider to assure that he or she will be able to see the member on a timely basis and make arrangements to follow up after the visit
Fill out part 1 of the Referral Authorization Form and fax it to HPSM at 650-829-2079
Do not send an unauthorized RAF to the specialist’s office
If HPSM approves your request, an authorized RAF will be faxed to the specialist’s office
Upon receipt, the specialist can contact the member to schedule an appointment

Referral Forms

Title
ACE Referral Authorization Form
Administrative Referral Authorization Form
Behavioral Health Referral Form
CBAS and MSSP Referral Form
Complex Case Management Referral Form
Home Health Physician Referral Form
Home Health Services - Retrospective Authorization Form
Pediatric Care Coordination Referral Form
Referral Authorization Correction Form
Referral Authorization Form

Out-patient referral:	650-829-2079
Behavioral Health and Recovery Services referral:	650-596-8065
CBAS and MSSP referral:	650-829-2047
Care Coordination referral:	650-829-2047