CurrentArizona Complete HealthPolicy 810

Utilization Management

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Governs integrated utilization-management processes for AHCCCS Contractors and Fee-for-Service programs across the continuum of care, including utilization review, discharge planning, prior authorization, service authorization, and medical-necessity decisions. The Federal Emergency Services Program is excluded.

Policy Summary

PayerArizona Complete Health

PolicyUtilization Management

Policy CodePolicy 810

Change TypeNo material change

Effective DateOct 1, 2026

Next Review DateN/A

Key ActionSubmit prior-authorization requests through at least two available delivery modes, such as telephone, fax, or an electronic portal.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

72 hoursInpatient admission review timeframe

7 business daysPost-hospital follow-up appointments

3 business daysPost-discharge follow-up call

2 modesProvider submission methods

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Utilization Management Coverage Criteria

Clinical criteria for utilization-management decisions

Written utilization-management criteria must meet all of the following requirements.

Clinical criteria governance

Required criterion attributes: Criteria are nationally recognized, objective, and evidence-based.
Application policies: Written policies explain how criteria are applied based on member needs and the local delivery system.
Provider participation: Involve appropriate providers in the review, development, and adoption of criteria.
Review and update: Review criteria and procedures for applying them annually and update them when appropriate.Annually

Institutional admission and concurrent-review medical necessity

Institutional admission and continued-stay decisions must address all applicable review elements.

Concurrent review

Clinical information: Consider symptoms, diagnostic test results, diagnoses, and required services.
Review factors: Assess the necessity of admission, appropriateness of the service setting, quality of care, length of stay, whether services meet member needs, discharge needs, and utilization patterns.
Initial stay: Base the initial institutional stay on adopted criteria, the member's specific condition, and the projected discharge date.
Continued stay: Base continued-stay decisions on written medical-care criteria assessing the need for continued hospitalization or institutional care; assign a new review date after each review and record it in the member's medical record.

Proactive discharge planning and transition coordination

Discharge planning must be proactive, individualized, coordinated, and continued across settings.

Proactive discharge planning

Member participation: Involve the member, Health Care Decision Maker, or Designated Representative; ensure understanding of the written discharge plan, instructions, and recommendations; and provide resources, referrals, and interventions for assessed or anticipated needs.
Follow-up: Arrange applicable physical-health and behavioral-health follow-up appointments and conduct a post-discharge follow-up call.Appointments within 7 business days; follow-up call within 3 business days
The appointment and call requirements have exceptions when the member is discharged to a facility where needs are evaluated by an appropriate healthcare professional.
Coordination: Coordinate safe and clinically appropriate placement, community supports, treatment-plan and medical-history communication, medications, equipment, nursing, therapies, hospice, advance care planning, community resources, and care-management referrals as needed.

Serious Mental Illness behavioral-health discharge

Discharge of a member with Serious Mental Illness from inpatient behavioral-health services must include all applicable elements.

SMI behavioral-health discharge

Community coordination: When community behavioral-health services are established, coordinate care among the inpatient facility, member, and established community behavioral-health providers before discharge.
Medication verification: Before discharge, actively verify prior or existing psychiatric and nonpsychiatric prescribed-medication documentation, including through the Health Information Exchange when applicable, and coordinate with identified prior or existing providers as needed.
Medication continuity: Arrange follow-up with a prescribing professional before existing prescriptions expire; if an appointment is unavailable, coordinate and document services to prevent a lapse in the member's ability to refill prescribed medication.Before prescription expiration

Prior authorization and service authorization requirements

Authorization processes must include all of the following operational safeguards.

Prior authorization program

Qualified staff: Use Arizona-licensed staff with appropriate clinical or pharmacy qualifications and training to apply medical criteria or make medical decisions.
Communication: Communicate to providers, members or representatives, other Contractors, and FFS Programs which services require or do not require authorization and the relevant clinical criteria.
Decision standards: Authorize services in an amount, duration, or scope sufficient to achieve the purpose for which they are furnished and apply review criteria consistently.
Peer-to-peer opportunity: Notify providers of the option to request a peer-to-peer discussion with the Medical Director during the prior-authorization process and before the Notice of Adverse Benefit Determination when additional information is requested or denial may result.

Authorization process

Coverage and authorization processes must satisfy all of the following requirements.

Authorization process requirements: Identify services requiring and not requiring prior authorization; communicate applicable clinical criteria; define initial and continuation authorization processes; authorize a sufficient amount, duration, or scope; apply criteria consistently; meet required response timeframes; consult requesting providers, other Contractors, or FFS Programs when appropriate; and review all prior-authorization requirements annually.Annual review of all prior-authorization requirements

Report the review and rationale for changes through the Medical Management Committee and document it in meeting minutes.

Medical necessity determination

Medical-necessity and coverage determinations must meet all of the following standards.

Medical necessity standards: Clearly document criteria and base them on reasonable medical evidence or a consensus of relevant healthcare professionals; do not arbitrarily deny or reduce a medically necessary service solely because of the setting, diagnosis, type of illness, or member condition; base service limits on a reasonable expectation that the authorized amount will achieve the expected outcome; and use board-certified professionals in medical-necessity determinations.

Applies to physical and behavioral-health services.

Third-party liability and secondary coverage

Requests involving Medicare or another third-party payer must be evaluated independently.

Third-party coverage coordination: Issue a timely independent coverage and medical-necessity determination whether the Contractor may be the secondary payer, another payer has not decided, or another payer has denied the request; do not rely on a third-party denial as the basis for the determination; and do not impose secondary prior authorization when the third party has approved the service through medical-necessity review.Applicable state and federal authorization timeframes

Third-party liability and coordination-of-benefits issues do not eliminate the Contractor's independent responsibility to evaluate the request.

Review consistency

Review staff must meet the following reliability standard.

Inter-rater reliability: Test all staff involved in prior authorization, concurrent review, and retrospective review and implement a corrective action plan for staff who do not meet the minimum compliance standard.Testing at least annually; minimum compliance standard of 90%

The process must ensure consistent application of review criteria.

Retrospective medical-necessity review

Retrospective review must satisfy all of the following requirements.

Retrospective review

Provider-Preventable Conditions: Do not reimburse additional hospital days or charges resulting from a Health Care-Acquired Condition or Other Provider-Preventable Condition; conduct a Quality of Care investigation and report the occurrence and results to AHCCCS Quality Management when the condition resulted from a hospital or medical-professional mistake or error.

New medical technologies and new uses

Evaluation of new technologies and new uses of existing technologies must include all of the following.

New technology evaluation: Evaluate benefits for medical and behavioral-health services, pharmaceuticals, and devices; conduct committee review; establish a timeframe for time-sensitive requests; consider Medicare coverage decisions, peer-reviewed literature, and federal and state Medicaid coverage decisions; assess whether the technology substantially improves diagnosis or treatment; evaluate trends in repeated requests; document determinations and rationale; and seek input from relevant specialists and professionals with expertise in the technology.Urgent determination no later than 72 hours from receipt; committee review quarterly

An urgent decision must be made as expeditiously as the member's condition warrants.

Clinical practice guidelines

Clinical practice guidelines must meet all of the following requirements.

Clinical practice guidelines: Develop or adopt guidelines for physical and behavioral-health services based on valid and reliable clinical evidence or professional consensus; consider member needs; adopt guidelines in consultation with contracted healthcare professionals and national practice guidelines; when national guidelines are unavailable, review relevant peer-reviewed U.S. medical literature; disseminate guidelines to affected providers and, upon request, to members, representatives, and potential members; and use them to support consistent utilization-management, education, and coverage decisions.Evaluate every 2 years

The Medical Management Committee must document guideline review, adoption, and efficacy evaluation in meeting minutes.

The Federal Emergency Services Program (FESP) is excluded from this policy. Providers should refer to the applicable AMPM Chapter 1100 requirements for FESP services.

Payment for services related to Provider-Preventable Conditions is prohibited. Additional hospital days or other charges resulting from a Health Care-Acquired Condition (HCAC) or Other Provider-Preventable Condition (OPPC) will not be reimbursed. When the condition results from a hospital or medical professional mistake or error, a Quality of Care investigation and reporting to AHCCCS Quality Management are required.

Provider Requirements and Operational Actions

Prior Authorization

Submit Prior-Authorization Requests Through the Applicable Process

FFS providers must follow the prior-authorization requirements in AMPM Policy 820. Providers serving members through a Contractor must use the Contractor’s approved prior-authorization process and submission channels.

Contractor authorization decisions are made by appropriately trained Arizona-licensed PA staff, including qualified nursing, physician, pharmacy, or behavioral-health professionals.
Emergency-service requirements are addressed in AMPM Policy 310-F.

Prior Authorization

Use Available PA Submission Channels

Submit prior-authorization requests through the Contractor’s available channels. The Contractor must maintain at least two provider submission modes, such as telephone, fax, or an electronic web portal.

Use the submission method identified in the Contractor’s provider materials or website.
Requests must include the information needed for the applicable authorization review.

Policy Scope and Program Context

This policy establishes integrated utilization-management requirements for AHCCCS Contractors and Fee-for-Service programs. It governs utilization review, concurrent review, discharge planning, prior authorization, service authorization, and medical-necessity determinations across the continuum of care, including preventive care, acute and long-term institutional care, behavioral health, community services, and hospice care. The program is intended to support appropriate use of health care resources, in the amount and duration necessary to achieve desired health outcomes, from preventive care through hospice and advance care planning.

Key Policy Definitions

Health Care-Acquired Condition (HCAC)

DefinitionA complication or condition resulting from hospital care or medical personnel.

Payment implicationAdditional hospital days or other additional charges resulting from the HCAC will not be reimbursed.

Quality-of-care reviewWhen the HCAC results from a mistake or error by a hospital or medical professional, the occurrence may require a Quality of Care investigation and reporting to AHCCCS Quality Management.

Other Provider-Preventable Condition (OPPC)

DefinitionA provider-preventable condition other than a Health Care-Acquired Condition.

Payment implicationPayment for services related to Provider-Preventable Conditions is prohibited.