Medicare Outpatient Authorization — Arizona
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Governs prior authorization requests for Medicare outpatient services for Arizona Complete Health Medicare members in Arizona, specifying submission channels, timelines, and required information for providers and facilities.
No material clinical or coverage changes in this revision.
Coverage and Eligibility
Coverage disclaimer and eligibility
Operational coverage stance and disclaimers
Form Coding and Quantity Details
| CPT/HCPCS | Primary and additional procedure codes requested on the form |
| ICD-10 | Diagnosis code field required |
| Total Units/Visits/Days | Total Units/Visits/Days (provider must specify) |
| 712 | Cochlear Implants & Surgery |
| 299 | Drug Testing |
| 922 | Experimental & Investigational Services |
| 205 | Genetic Testing & Counseling |
| 249 | Home Health |
| 225 | Home Meals |
| 290 | Hyperbaric Oxygen Therapy |
| 395 | Infertility Diagnosis or Treatment |
| 729 | Neuropsychological Testing |
| 410 | Observation |
| Start Date OR Admission Date | Start Date OR Admission Date (MMDDYYYY) |
| End Date OR Discharge Date | End Date OR Discharge Date (MMDDYYYY) |
| Modifier | Modifier field for procedure codes |
Submission Channels, Timelines, and Required Documentation
Use designated fax/phone by request type
Submit outpatient authorization requests using the designated fax numbers or phone lines for each request type: All Part B drug requests must be faxed to 844-235-5090; expedited requests use phone lines (Non‑Duals: 1-800-977-7522; Duals: 1-855-445-3580); standard requests fax to 877-808-9362; transplant requests fax to 833-974-3120; behavioral health requests fax to 844-918-1192.
- All Part B Drug Requests: Fax 844-235-5090
- Expedited Requests Non Duals: Call 1-800-977-7522
- Expedited Requests Duals: Call 1-855-445-3580
- Standard Requests: Fax 877-808-9362
- Transplant Requests: Fax 833-974-3120
- Behavioral Health Requests: Fax 844-918-1192
Standard request steps and 7‑calendar‑day decision timeframe
For standard (elective admission) requests, complete the authorization form and fax it to the appropriate department listed above. A determination will be made as expeditiously as the enrollee's health condition requires, but no later than 7 calendar days after receipt of the request.
- Complete the form fully and fax to the department matching the request type.
- Decision timeframe: no later than 7 calendar days after receipt.
Expedited requests: contact routes and clinical threshold
Expedited requests must be telephoned rather than faxed: Non‑Dual members call 1-800-977-7522 and Dual members call 1-855-445-3580. An expedited request is used when waiting for a standard decision could place the enrollee's life, health, or ability to regain maximum function in serious jeopardy.
- Non‑Dual expedited contact: Call 1-800-977-7522
- Dual expedited contact: Call 1-855-445-3580
- Clinical threshold: waiting could seriously jeopardize life, health, or ability to regain maximum function
Form completion and required supporting clinical documentation
Complete all required fields on the authorization form; incomplete forms will be rejected. Include copies of all supporting clinical information with the submission — lack of clinical information may result in delayed determination.
- All required fields must be filled in; incomplete forms will be rejected.
- Copies of all supporting clinical information are required.
- Absence of clinical information may delay the determination.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.