What is Prior Authorization

Prior Authorization (PA) is a process by which the AHCCCS Division of Fee-For-Service (FFS) Management (DFSM) determines in advance whether a service that requires prior approval will be covered, based on the initial information received. PA may be granted provisionally (as a temporary authorization) pending the receipt of required documentation to substantiate compliance with AHCCCS criteria.

PA does not guarantee payment. Reimbursement is based on the accuracy of the information received with the original PA, on whether or not the service is substantiated through concurrent and/or medical review, and on whether the claim meets claims submission requirements.   (See AMPM 820)

The following services are not handled by DFSM. You must contact the appropriate entity for authorization:

  • Non-Acute Services for Tribal ALTCS Program members - contact Tribal Case Manager.
  • Transplant Services - contact Medical Management in the AHCCCS Division of Health Care Management (DHCM).
  • Prescription Medication - contact the contracted Pharmacy Benefit Manager (PBM), Optum Rx at (855) 577-6310.
  • Behavioral Health PA Requests for Acute FFS members assigned to the RBHA – contact the RBHA.