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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

Frequently asked questions

Submitting a prior authorization request to SCFHP

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

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.