Prior Authorization for Treatment

Form instructions

Please make sure your form meets the following requirements – failure to do so will result in a rejected request:

  1. Use the current Prior Authorization Request Form (version 3.2 September 2020)
  2. Use the fillable form (typed, not hand-written)
  3. Only select “Urgent” if it’s truly an urgent matter. Most requests will be “Routine” requests
  4. Do not check the “LTC” box unless you are truly a long-term care provider or facility

Response times

For authorization requests submitted prior to the date of service, expect a response from HPSM:

  • 72 hours for urgent (a delay in care could seriously jeopardize the life or health of the patient or the patient's ability to regain maximum function and/or a delay in care would subject the member to severe pain that cannot be adequately managed without the care or treatment requested in the prior authorization).
  • 5 business days for routine (all other requests).

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  • An outdated version of the form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 call Provider Services at 650-616-2106 or consult the Prior Authorization Request Form User Guide.

Current Authorization List

Before submitting a request form, search HPSM's Prior Authorization List by CPT code or service name to see if you need to get prior authorization.

 View the list |   Download the list

HPSM regularly updates our list of authorization codes to reflect current clinical guidelines. Archived lists are published on our PAR List Changes page.

Read our notification regarding the most recent code changes: Q3 Prior Authorization and Covered Services Changes Effective 9/1/2021

Inpatient Authorizations

  • For all inpatient admissions, HPSM should be notified within 24 hours or the next business day.
  • For admission notification, fax face sheet to 650-829-2060. When attaching clinical information, please place the face sheet before the clinicals.
  • Do not submit notification for admissions to observation status. Observation status is direct billable.
  • Do not submit requests for services delivered in the emergency room. Emergency room services are direct billable.
  • Clinical information for concurrent review should be faxed to 650-829-2068

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