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
- Pharmacy Benefit - DualConnect List of Covered Drugs (Formulary)
- Pharmacy Benefit - DualConnect Drug Prior Authorization Requirements
Prior authorization request forms
- Prior Authorization Request – Medical Services
- 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
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
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
For patients who are delegated to a group, please contact the group directly to submit a prior authorization request.
Valley Health Plan (VHP)
- Phone: 1-408-885-4647
- Fax: 1-408-885-4875
Physician Medical Group/Excel MSO
- Phone: 1-408-937-3645
- Fax: 1-408-937-3637
Premier Care of Northern California (PCNC)/Conifer Health
- Phone: 1-818-461-5006
- Fax: 1-818-817-5155
You have the right to ask us to review our decision by asking for an appeal.
Call us for more information:
- DualConnect 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.
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