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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

Post-stabilization care prior authorization

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

North East Medical Services (NEMS)
Phone: 1-408-573-9686

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

Submitting a prior authorization request to SCFHP for medical services

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 at1-408-874-1957 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.

Medical Services, Durable Medical Equipment and Medical Supplies:

  • Routine request:
    5 business days for Medi-Cal
    14 calendar days for DualConnect
  • Urgent request:
    72 hours for both Medi-Cal and DualConnect

Physician administered drugs:

  • Routine request:

24 hours for Medi-Cal

72 hours for DualConnect

  • Urgent request:

24 hours for both Medi-Cal and DualConnect

Delegated authorizations

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

What to do if you disagree with a coverage decision

You have the right to ask us to review our decision by asking for an appeal.

Call us for more information:

To schedule a peer-to-peer discussion with a physician reviewer, please call 1-408-874-1451.

You may obtain a copy of the criteria on which a UM decision was based on by calling us at 1-408-874-1821 or sending a request in writing to the following address:

Attn: Utilization Management Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158