Prior Authorization for Treatment

Prior Authorization List

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.

Only valid codes will be reviewed. Please refer to CMS/MC guidelines to verify validity. Codes are updated regularly and posted on our Authorizations page.

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. 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 9/01/2018

The HPSM Prior Authorization Required List states which service codes require prior authorization. Services not listed here do not require prior authorization. For services on this list, complete the Prior Authorization Request Form and fax it to HPSM at 650-829-2079.

Prior Authorization Request Form

Your PAR will be rejected if you submit:

  • An outdated version of the form
  • An incomplete form
  • Inaccurate information
  • A form filled out in handwriting
  • A PAR with multiple patients’ information

HPSM recommends adjusting your fax machine settings to the highest quality possible, and double-checking the member ID number before sending. If you have any questions about the PAR, please consult the Prior Authorization Request Form User Guide or call Provider Services at 650-616-2106.

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.

Authorization Fax Numbers

HPSM has several direct fax lines dedicated to specific form submissions:

In-patient admissions with facesheet for all lines of business (including in-patient retros and corrections): 

650-829-2060

In-patient admissions, clinicals only (without facesheet)

650-829-2068

Out-patient retro authorizations and corrections

650-829-2062

PCP referrals for Behavioral Health and Recovery Services

650-596-8065

Pharmacy authorizations and modifications to formulary

650-829-2045

CBAS and MSSP referrals, Care Coordination

650-829-2047

When including clinicals:

  • Place the facesheet before any clinical information
  • Do not submit observation requests: observation status is direct billable
  • Do not submit requests for services delivered in the emergency room: these are direct billable