The following guidelines will help providers determine when Prior Authorization is required. This is not an exhaustive list. For more detail, see Chapters 300, 400, 800, and 1100 of the AHCCCS Medical Policy Manual (AMPM), and Chapter 8 of the FFS Provider Billing Manual.
PA is issued for AHCCCS covered services within certain limitations, based on the following:
- The member’s AHCCCS eligibility;
- Provider status as an AHCCCS-registered FFS provider;
- The service requested is an AHCCCS covered service requiring PA;
- Information received from the provider meets the requirements for issuing a PA number;
- The service requested is not covered by another primary payer (e.g., commercial insurance, Medicare, other agency).
Prior Authorization is not required for:
- FFS members receiving services from Indian Health Services (IHS)/638 providers and facilities
- Emergency services
- FESP members*
A non-IHS/638 provider or facility rendering AHCCCS covered services that require prior authorization must obtain PA from DFSM.
Long Term Care services for Tribal ALTCS members are authorized by the member’s ALTCS tribal case manager. PA requests must be submitted prior to providing services.
For PA information and documentation requirements related to specific services, please see AMPM 820.
*Extended services enrollment is required for coverage of Outpatient Dialysis for FESP members.
Requirements for Outpatient Dialysis for FESP members:
- The treating physician has submitted the completed and signed Initial Dialysis Case Creation Form to AHCCCS; and
- The treating provider has completed and signed a Monthly Certification of Emergency Medical Condition for the month in which outpatient dialysis services are received.
The monthly certification form is retained in the member’s records by the treating physician and must include the treating physician’s opinion stating that the failure of the FESP member to receive dialysis at least three times per week would reasonably be expected to result in:
- Placing the member’s health in serious jeopardy, or
- Serious impairment of bodily function, or
- Serious dysfunction of a bodily organ or part.
Services that require Prior Authorization:
- Behavioral Health Residential Facility Documentation Requirements [BHRF in Word Version]
- Behavioral Health Residential Facility AMPM 320-V Guidance
- Non Emergency Acute Inpatient Admissions
- Level I Behavioral Health Inpatient Facility and RTC Admissions
- Elective (scheduled) Hospitalizations
- Elective Surgeries
- Medical Equipment (DME) > $300.00
- Medical Supplies (consumable) >$100.00 and all rentals and repairs.
- Home Health
- Skilled Nursing Facility
- Non-Emergency Transportation > 100 miles
For urgent requests please see: https://www.azahcccs.gov/PlansProviders/FeeForServiceHealthPlans/PriorAuthorization/submissionprocess.html
Services that do not require Prior Authorization:
- Services performed during a Retroactive Eligibility Period
- When other coverage is primary, e.g.: Medicare or Commercial Insurance
- Emergency Medical Hospitalization < 72 hours
- Emergency Admission to Behavioral Health Level 1 Inpatient facility requires AHCCCS notification within 72 hours from admission and concurrent review every 7 days
- Diagnostic procedures, e.g., EKG, MRI, CT Scans, X-rays, Labs, colonoscopy, EGD, Sleep Studies, cardiac catheterization
- Non–Surgical Procedures, e.g., PICC Line/Central Line removal or placement, PEG removal, Blood Transfusions
- Outpatient Chemotherapy and Non IMRT Radiation
- Emergency Dental and Dental Services for Members < 21 years old (AMPM Ch. 400), Some dental services for members < 21 do require prior authorization – see Ch 431 & Ch 820
- Emergency Dental Services for Members age 21 years and older up to the $1000 limit (AMPM Policy 310-D1)
- Eye Glasses for members < 21 years old
- Family Planning Services
- Physician Consultations and Office Visits
- Prenatal Care
- Emergency Transportation
- Non-Emergency Transportation of less than 100 miles