Prior Authorization for Referrals
An HPSM-contracted PCP can refer patients to:
- HPSM-contracted specialists without prior authorization
- Specialists outside of HPSM’s network if an appropriate in-network specialist is not available
To refer to a non-network specialist:
- 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
ACE Referral Authorization Form
(384 KB)
Behavioral Health Referral Form
(217 KB)
CBAS and MSSP Referral Form
(93 KB)
HomeAdvantage Program Referral Form
(357 KB)
Referral Authorization Fax Numbers
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 |