How to Complete the Health Plan of San Mateo Prior Authorization Form

The Health Plan of San Mateo prior authorization form is a single-page request that providers complete and send to HPSM’s Health Services Department by fax, through the Provider Portal, or by mail. HPSM publishes two versions: a medical form for procedures and services, and a separate pharmacy form for prescription drugs. Picking the right one, filling every field, and attaching clinical documentation are what keep a request moving instead of bouncing back.

Where To Download the Right Form

The medical Prior Authorization Request Form is a downloadable PDF on HPSM’s provider forms page at hpsm.org/provider/resources/forms.¹ The pharmacy version is a different document, formally titled the Prescription Drug Prior Authorization or Step Therapy Exception Request Form, with different fields and a different fax destination.² Confirm which one you need before you start. A medical form submitted for a drug request (or the reverse) lands with the wrong reviewers.

What To Gather Before You Open the Form

Have everything in front of you before you begin. Looking up a code mid-submission is how fields end up blank.

Member identifiers: the patient’s full legal name (last name and first name with middle initial), date of birth, and HPSM Member ID.³
Provider identifiers: the requesting provider’s name and NPI, plus the servicing provider’s name and NPI if a different provider will perform the service. The form does not ask for a Tax ID.³
Codes: at least one ICD-10 diagnosis code with a written description, plus the CPT or HCPCS procedure code for each requested service line.³
Supporting clinical documentation: recent office notes, lab or imaging results, pathology findings, and any prior treatment history that shows why the service is medically necessary.

Filling Out the Medical Form

Work top to bottom. Start with the member block (name, ID, date of birth), then the requesting provider block with your name and NPI. If the service will be delivered by a specialist or facility, fill in the servicing provider section. Leaving that section blank on a referral is a common reason reviewers come back for more information.

The clinical section asks for a primary diagnosis code and description, then numbered service lines where you enter each CPT or HCPCS code, any applicable modifier, the number of units, and the requested dates of service.³ Check each code against the current HPSM CPT Code PAR List before you submit. Some codes require authorization only under certain conditions. Speech therapy codes, for example, require authorization for members under 21 or in a skilled nursing facility, but the first 20 combined therapy visits for adults do not.⁴

Routine or Urgent

Two checkboxes mark urgency. Routine covers elective services where a short wait will not harm the patient. Urgent is reserved for cases where delay could seriously jeopardize the patient’s life or health, compromise the ability to regain maximum function, or subject the member to severe pain that cannot be managed without the treatment.⁵ Checking Urgent without clinical justification does not speed anything up. Reviewers will reclassify it as routine if the documentation does not support the designation.

Attach the Clinical Evidence

The notes you append are what the medical director actually reads to decide the case. Include the most recent visit note showing current status, relevant test results, and any prior treatment history that explains why the requested service is the appropriate next step. A completed form with codes but no clinical backup is the fastest path to a denial for insufficient information.

How To Submit the Completed Form

HPSM runs six authorization fax lines. Sending to the wrong one puts your request in the wrong queue until someone redirects it.

Inpatient admissions with facesheet: 650-829-2060
Inpatient admissions, clinicals only (no facesheet): 650-829-2068
Outpatient authorizations: 650-829-2079
Pharmacy authorizations: 650-829-2045
CBAS, MSSP referrals, and care coordination: 650-829-2047
Behavioral health PCP referrals: 650-596-8065

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The HPSM Provider Portal is the other main submission channel. Registered users can submit requests electronically and track status online. New users register at hpsm.org/provider/portal or by calling 650-616-2106.⁶ Portal submissions feed directly into HPSM’s processing system and generally reach reviewers faster than fax.

For physical mail, send the form and documentation to Health Plan of San Mateo, 801 Gateway Blvd., Suite 100, South San Francisco, CA 94080.³ Mail is slow and not practical for anything time-sensitive. Whichever channel you use, keep the fax confirmation or portal receipt. That timestamp is when the decision clock starts.

The Pharmacy Form Is Different

Drug requests use the pharmacy form and a different pathway. The fields are patient information, prescriber details with individual NPI, the requested medication with dose and quantity, and ICD-10 diagnosis codes.² There are no CPT or HCPCS fields because no procedure is involved. Fax the completed pharmacy form to 650-829-2045.⁷

If the medication requires step therapy, request an exception on the same pharmacy form by documenting which drugs or products the patient previously tried and the specific clinical reasons those alternatives do not meet the patient’s needs.⁸

How Long the Decision Takes

California law caps the review time. Routine requests get a decision within five business days from the date HPSM receives all reasonably necessary information. If HPSM pends the request for more documentation, the five-day clock does not start running until you provide it. Urgent requests get a decision within 72 hours of receipt.⁹ HPSM confirms the 72-hour standard on its submissions page.⁵ Notification goes to both provider and member.

Checking Status

The Provider Portal shows real-time status, which is the fastest way to see whether a request is still under review, pending more information, or decided.⁶ You can also call HPSM Health Services at 650-616-2070 for authorization questions.³ If the status reads “pending additional information,” respond quickly. The decision clock is paused until you do.

If the Request Is Denied

A denial notice includes the reasons and information about the member’s right to appeal. For medical denials, the appeal runs through the member appeals process, not the provider dispute resolution system. HPSM’s PDR process explicitly excludes pre-service authorization denials.¹⁰ Denials based on medical necessity are reviewed by the Medical Director, or by a Clinical Pharmacist for physician-administered drugs. CareAdvantage members have 65 calendar days from the date of HPSM’s Notice of Denial to file an appeal.¹¹

Pharmacy denials are appealed through Medi-Cal Rx rather than HPSM directly. Providers and members each have 180 days from the initial denial to submit an appeal through the Medi-Cal Rx Provider Portal, fax, or U.S. mail. Medi-Cal Rx processes pharmacy appeals within 60 calendar days.¹¹

Mistakes That Slow Requests Down

Most problems are avoidable. The recurring ones:

Wrong fax number. An outpatient request faxed to the inpatient line sits in the wrong queue.
Missing clinical documentation. Codes without notes give the reviewer nothing to evaluate, and the request gets pended.
Incorrect urgency designation. Marking routine work as urgent without supporting documentation gets reclassified and can add processing time.
Procedure code not on the PAR list. Not every service requires authorization. Check the HPSM CPT Code PAR List before submitting.⁴
Using the medical form for a drug request. Pharmacy authorizations need the pharmacy form and the 650-829-2045 fax line.

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Health Plan of San Mateo. Provider Forms
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San Mateo County Health. Prescription Drug Prior Authorization or Step Therapy Exception Request Form
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Health Plan of San Mateo. Health Plan of San Mateo Prior Authorization Request Form
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Health Plan of San Mateo. HPSM CPT Code PAR List
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Health Plan of San Mateo. Submitting Prior Authorization Requests
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Health Plan of San Mateo. Provider Portal / eReports
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Health Plan of San Mateo. Authorizations Fax Numbers
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Medi-Cal Rx. Changes to Medi-Cal Rx, Effective January 1, 2026
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California Legislative Information. California Health and Safety Code 1367.01
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Health Plan of San Mateo. Provider Disputes
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Health Plan of San Mateo. Summary of Changes for 2025 HPSM Provider Manual