Prior Authorization for Treatment
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 7/01/2019
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.
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- An outdated version of the form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):
In-patient admissions, clinicals only (without facesheet)
Out-patient retro authorizations and corrections
PCP referrals for Behavioral Health and Recovery Services
Pharmacy authorizations and modifications to formulary
CBAS and MSSP referrals, Care Coordination
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