Prior Authorization Forms 

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Prior Authorization Forms

The Prior Authorization (PA) unit at AHCCCS authorizes specific services prior to delivery of medical related services.

PA request status can be viewed online.

Forms used in PA Unit include the following:

The Initial Dialysis Case Creation Form is the first form that is completed by registered providers to establish a Federal Emergency Services Program (FESP) member on the Extended Service Program. This program provides any dialysis related services for the member's End Stage Renal Disease (ESRD). The form must be completed in its entirety.

Initial Dialysis Case Creation Form | Rich Text Version

Contacts

You may fax the Fee For Service Prior Authorization Request Form to the AHCCCS FFS Prior Authorization Unit to request authorization, or you may use AHCCCS Online to enter a pended authorization request online, 24 hours a day/7 days a week.

To obtain a pended authorization for services requiring expedited review, or for prior authorization related inquiries, providers can call the FFS Prior Authorization line, Monday through Friday between 9am to 11:30am, and 12:30pm to 4pm. FFS The Prior Authorization area is closed on weekends and holidays.

Fee For Service Authorization Phone Line

  • Within Maricopa County: 602-417-4400, Select option 1 for transportation
  • Statewide: 1-800-433-0425
  • Outside Arizona: 1-800-523-0231
  • FESP Dialysis: 602-417-7548

Fee For Service Authorization Fax Numbers

  • Prior Authorization Fax: 602-256-6591
  • Transportation Fax: 602-254-2431
  • Utilization Review Fax: 602-254-2304
  • Long Term Care Fax: 602-254-2426

Allow at least three working days for your faxed request to be processed.

The Monthly Certification Form is for the Federal Emergency Services Program (FESP) member. The program provides for the dialysis related care for the member's End Stage Renal Disease (ESRD).

Monthly Certification of Emergency Medical Condition

This form provided must be completed monthly, maintained in the member's file at your office, and be available to AHCCCS on request if needed.

Contacts

You may fax the Fee For Service Prior Authorization Request Form to the AHCCCS FFS Prior Authorization Unit to request authorization, or you may use AHCCCS Online to enter a pended authorization request online, 24 hours a day/7 days a week.

To obtain a pended authorization for services requiring expedited review, or for prior authorization related inquiries, providers can call the FFS Prior Authorization line, Monday through Friday between 9am to 11:30am, and 12:30pm to 4pm. FFS The Prior Authorization area is closed on weekends and holidays.

Fee For Service Authorization Phone Line

  • Within Maricopa County: 602-417-4400, Select option 1 for transportation
  • Statewide: 1-800-433-0425
  • Outside Arizona: 1-800-523-0231
  • FESP Dialysis: 602-417-7548

Fee For Service Authorization Fax Numbers

  • Prior Authorization Fax: 602-256-6591
  • Transportation Fax: 602-254-2431
  • Utilization Review Fax: 602-254-2304
  • Long Term Care Fax: 602-254-2426

Allow at least three working days for your faxed request to be processed.

The Prior Authorization Correction Form is to be utilized to request changes to an existing Prior Authorization. Any additional medical documentation for this request should be submitted with this request. The form must be completed in its entirety.

Prior Authorization Correction Form

Contacts

You may fax the Fee For Service Prior Authorization Request Form to the AHCCCS FFS Prior Authorization Unit to request authorization, or you may use AHCCCS Online to enter a pended authorization request online, 24 hours a day/7 days a week.

To obtain a pended authorization for services requiring expedited review, or for prior authorization related inquiries, providers can call the FFS Prior Authorization line, Monday through Friday between 9am to 11:30am, and 12:30pm to 4pm. FFS The Prior Authorization area is closed on weekends and holidays.

Fee For Service Authorization Phone Line

  • Within Maricopa County: 602-417-4400, Select option 1 for transportation
  • Statewide: 1-800-433-0425
  • Outside Arizona: 1-800-523-0231
  • FESP Dialysis: 602-417-7548

Fee For Service Authorization Fax Numbers

  • Prior Authorization Fax: 602-256-6591
  • Transportation Fax: 602-254-2431
  • Utilization Review Fax: 602-254-2304
  • Long Term Care Fax: 602-254-2426

Allow at least three working days for your faxed request to be processed.

The Fee For Service (FFS) Prior Authorization Request Form is to be completed by registered providers to request an authorization. Providers should fax the completed FFS Prior Authorization Request Form as the coversheet for the supporting documentation they are submitting with the request. All mandatory fields on the form must be completed accurately in order to avoid delays in receipt, and processing of authorization requests.

Prior Authorization Request Form

Contacts

You may fax the Fee For Service Prior Authorization Request Form to the AHCCCS FFS Prior Authorization Unit to request authorization, or you may use AHCCCS Online to enter a pended authorization request online, 24 hours a day/7 days a week.

To obtain a pended authorization for services requiring expedited review, or for prior authorization related inquiries, providers can call the FFS Prior Authorization line, Monday through Friday between 9am to 11:30am, and 12:30pm to 4pm. FFS The Prior Authorization area is closed on weekends and holidays.

Fee For Service Authorization Phone Line

  • Within Maricopa County: 602-417-4400, Select option 1 for transportation
  • Statewide: 1-800-433-0425
  • Outside Arizona: 1-800-523-0231
  • FESP Dialysis: 602-417-7548

Fee For Service Authorization Fax Numbers

  • Prior Authorization Fax: 602-256-6591
  • Transportation Fax: 602-254-2431
  • Utilization Review Fax: 602-254-2304
  • Long Term Care Fax: 602-254-2426

Allow at least three working days for your faxed request to be processed.

The Medical Documentation Form The Medical Documentation Form is to be utilized when submitting additional documentation that has not been previously submitted and is needed to substantiate medical necessity and appropriateness of services requested. This form should also be used when submitting additional documentation for concurrent review or when a Prior Authorization has been pended requesting additional documentation.

Medical Documentation Form 

Contacts

You may fax the Fee For Service Prior Authorization Request Form to the AHCCCS FFS Prior Authorization Unit to request authorization, or you may use AHCCCS Online to enter a pended authorization request online, 24 hours a day/7 days a week.

To obtain a pended authorization for services requiring expedited review, or for prior authorization related inquiries, providers can call the FFS Prior Authorization line, Monday through Friday between 9am to 11:30am, and 12:30pm to 4pm. FFS The Prior Authorization area is closed on weekends and holidays.

Fee For Service Authorization Phone Line

  • Within Maricopa County: 602-417-4400, Select option 1 for transportation
  • Statewide: 1-800-433-0425
  • Outside Arizona: 1-800-523-0231
  • FESP Dialysis: 602-417-7548

Fee For Service Authorization Fax Numbers

  • Prior Authorization Fax: 602-256-6591
  • Transportation Fax: 602-254-2431
  • Utilization Review Fax: 602-254-2304
  • Long Term Care Fax: 602-254-2426

Allow at least three working days for your faxed request to be processed.

The Optum Rx Prior Authorization Request Form is used when the provider requests consideration on behalf of an AHCCCS Fee-For-Service (FFS) recipient for a drug not listed on the AHCCCS FFS Drug List. This form only applies to AHCCCS FFS recipients and is not valid for recipients enrolled in other AHCCCS Contractor Managed Care Plans.

FFS Medication Request Form

All prior authorization requests must be faxed to Optum Rx at 1-866-463-4830. After faxing the Prior Authorization request form above, you may contact Optum Rx’s Customer Service at 1-855- 577-6310 to check the status of a submitted prior authorization request.

Please allow 24 hours for your request to be processed. Incomplete requests may delay this process.

Can't find what you're looking for? Please visit the AHCCCS Document Archive.
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