Authorization for services
Your doctor or healthcare provider may need approval from Santa Clara Family Health Plan (SCFHP) before we cover certain services. This is called prior authorization, also known as a service authorization request (SAR) or organization determination. Here are answers to common questions about the process.
How are decisions made?
Before approving services, SCFHP must have all the facts. That includes exam and test results to support your doctor's diagnosis and treatment recommendations. Decisions are made by either a licensed physician or other healthcare professional.
How long does the process take?
For services that are not urgent, decisions are made within five working days or 14 days from when we get the request.
- Medi-Cal members, we will make our decision within five working days.
- DualConnect members, we will make our decision within 14 days.
If your doctor or health care provider believes that following the standard timeframe could affect your life or well-being, we will make an urgent decision.
- Medi-Cal members, we will make our decision within 72 hours.
- DualConnect members, we will make our decision within 72 hours.
How do we tell you of a decision?
You will receive a letter notifying you of the decision. In some cases, we may also call you. If the services are denied, we will send you and your provider a Notice of Action (NOA) letter. This NOA letter will tell you why we denied the services and how you can file an appeal if you do not agree with the decision.
For more information, please see your Member Handbook.
- Medi-Cal members, visit Forms & Documents to see the Member Handbook.
- DualConnect members, visit Member Materials to see the Member Handbook.