Prior authorization

• 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

• Case Management Referral Form
• Health Homes Program Referral Form

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

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