Arizona Standardized Prior Authorization Request for Medication, DME, and Medical Device
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This document provides the Arizona Complete Health standardized prior authorization submission form and instructions for medications (pharmacy and provider-administered), durable medical equipment (DME), prosthetics/orthotics, and medical devices for use by providers submitting authorization requests.
No material clinical or coverage changes in this revision.
Submission and Documentation Criteria
Submission and evidence requirements
Information required to support a coverage determination includes:
Request Coding and Service Type Codes
| HCPCS | Field available for provider-administered drugs or devices (HCPCS Code) |
| NDC | Field available for drug NDC numbers and compound ingredient NDCs |
| ICD-10 | Fields for ICD-10 diagnosis codes related to request |
How to Submit and Provider Responsibilities
Submission channels by service type
Submit prior authorization requests using the channel that matches the service type: pharmacy requests via the Cover My Meds portal or Fax 800.977.4170; medical/provider-administered drugs, J-code/buy-and-bill, medical devices, DME, and O&P via the AzCH Provider Portal or Fax 866.597.7603.
- Pharmacy: Cover My Meds portal or Fax: 800.977.4170
- Medical drugs/J‑Code/buy‑and‑bill/Medical Device/DME/O&P: AzCH Provider Portal or Fax: 866.597.7603
Request type, reason selection, and expedited review option
Indicate whether the request is an Initial Request or a Continuation/Renewal and check all applicable reason(s) for the request (e.g., Prior Authorization, Step Therapy/Formulary Exception, Medical Device, Quantity Exception, DME, Specialty Drug, Other). If the situation may seriously jeopardize the patient’s life, health, or ability to regain maximum function, check the Expedited/Urgent Review box and have the prescriber or designee sign to certify urgency.
- Select one: Initial Request or Continuation/Renewal.
- Check all reasons that apply (Prior Authorization, Step Therapy/Formulary Exception, Medical Device, Quantity Exception, DME, Specialty Drug, Other).
- For expedited/urgent review, check the Expedited/Urgent Review box and obtain prescriber (or designee) signature certifying that standard review time may seriously jeopardize the patient.
Attach clinical support and payment disclaimer
Attach copies of supporting clinical information and complete all required fields on the form; incomplete fields or lack of clinical information may result in a rejected form or delayed determination. Note that an authorization decision is not a guarantee of payment—member eligibility and medical necessity will be verified at time of service.
- ALL REQUIRED FIELDS MUST BE COMPLETED TO AVOID A REJECTED FORM.
- COPIES OF SUPPORTING CLINICAL INFORMATION REQUIRED; LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION.
- Authorization is not a guarantee of payment; member must be eligible and services must be a covered benefit and medically necessary.
Key Definitions
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