Prior authorization
Welcome to the Santa Clara Family Health Plan (SCFHP) provider resources page for prior authorization requests. This page provides resources and instructions on:
- How and when to submit prior authorization requests to SCFHP
- Emergency admission notification
- Delegated authorizations
- What to do if you disagree with a coverage decision
Resources and forms
- Medical Covered Services Prior Authorization Grid
- Medical Benefit Drug Prior Authorization Grid
- Durable Medical Equipment List – Specialty Devices
- Durable Medical Equipment List – Brands
- Drug Prior Authorization Requirements – Medi-Cal (Formulary)
- Drug Prior Authorization Requirements - Cal MediConnect (Formulary)
Prior authorization request forms
- Prior Authorization Request – Medical Services
- Prior Authorization Request – Prescription Drug
- Prior Authorization Request – Prescription Drug (Part D)
- Prior Authorization Request – Transportation
Managed long-term services and supports
- Long-Term Care – Authorization Form
- Bed Hold Authorization Request Form
- Long-Term Care – Discharge Notification Form
Referral forms
Post-stabilization care prior authorization request available 7 days a week, 24 hours a day.
Santa Clara Family Health Plan
Phone: 1-408-874-1828
VHP Network
Phone: 1-855-254-8264
Kaiser Permanente Network
Phone: 1-800-447-3777
Palo Alto Medical Foundation
Phone: 1-408-874-1828
Physician’s Medical Group (PMG)
Phone: 1-408-937-3600, option 2
Premier Care of Northern California (PCNC)
Phone: 1-818-624-0381
Frequently asked questions
Most elective services require prior authorization. Please see the prior authorization grid for more information on the services that require prior authorization. To request a review to authorize a patient’s treatment plan, please complete the prior authorization request form and fax it to the Utilization Management Department at 1-408-874-1957 along with clinical documentation to support the request.
Urgent referrals should only be submitted if the normal time frame for authorization will:
- Be detrimental to the patient’s life or health, or
- Jeopardize patient’s ability to regain maximum function, or
- Result in loss of life, limb, or other major bodily function
Referrals that do not meet the above urgent referral criteria will be downgraded to a routine referral request and follow standard turn-around times.
- Routine request:
5 business days for Medi-Cal
14 calendar days for Cal MediConnect - Urgent request:
72 hours for both Medi-Cal and Cal MediConnect
For patients who are delegated to a group, please contact the group directly to submit a prior authorization request.
Valley Health Plan (VHP)
Physician Medical Group/Excel MSO
Premier Care of Northern California (PCNC)/Conifer Health
You have the right to ask us to review our decision by asking for an appeal.
Call us for more information:
- Cal MediConnect Customer Service: 1-877-723-4795
- Medi-Cal Customer Service: 1-800-260-2055
To schedule a peer-to-peer discussion with a physician reviewer, please call 1-408-874-1451.