Medicare Inpatient Authorization — Arizona
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Forms and procedures for requesting prior authorization for Medicare inpatient admissions for Arizona Complete Health members, including expedited and concurrent request pathways and required information providers must submit.
No material clinical or coverage changes in this revision.
Coverage and Authorization Timelines
Authorization submission and timelines
Authorization processed when provider submits a complete form with supporting clinical information; timelines depend on request type.
All required fields must be completed; incomplete forms will be rejected
Expedited request phone lines differ for Dual vs Non-Dual members
An authorization is not a guarantee of payment. The member must be eligible at the time services are rendered, and the service must be a covered Health Plan benefit and medically necessary to be payable. Prior authorization alone does not satisfy these requirements and does not guarantee reimbursement.
Service Type and Procedure Codes
| 779 | C-Section |
| 121 | Long Term Acute Care |
| 970 | Medical |
| 414 | Premature / False Labor |
| 427 | Rehab |
| 402 | Skilled Nursing Facility |
| 492 | Subacute |
| 411 | Surgical |
| 992 | Transplant |
| 720 | Vaginal Delivery |
Prior Authorization Process and Required Provider Documentation
Prior Authorization Required
Inpatient prior authorization is required for admissions. Submit the completed inpatient authorization request form to the payer using the appropriate fax or phone pathway for the request type (standard/elective, expedited, concurrent, behavioral health). Include the primary procedure code and modifier, any additional procedure codes and modifiers, diagnosis code(s), admission or start date, and discharge date or expected length of stay.
- For Standard (Elective Admission) requests: complete the form and fax to the Standard Requests number.
- For Expedited requests: Non‑duals call 800-977-7522; Duals call 1-855-445-3580.
- For Concurrent requests (including inpatient stays already admitted, ER admits, direct admits): fax to 844-419-6538. Determinations within 72 hours.
- Behavioral Health requests: fax to 844-918-1192.
Provider Action / Operative Provider Alert
Operative providers and admitting clinicians must initiate the prior authorization request for inpatient stays and ensure the form is fully completed and routed promptly. For behavioral health admissions use the behavioral health request pathway and include the BH admission reason code where applicable.
- Include the BH reason code when applicable (e.g., 528 Chemical Substance Abuse, 529 Psychiatric Admission).
- Ensure requests are submitted to the correct department based on request type to avoid processing delays.
Required Documentation
All required fields on the authorization form must be completed and copies of supporting clinical documentation must be attached. This includes, at minimum: primary procedure (CPT/HCPCS) and modifier, additional procedure codes/modifiers, ICD-10 diagnosis code(s), admission/start date, discharge date or anticipated length of stay, and any relevant clinical notes, operative reports, imaging, or test results.
- Complete every required field on the form — incomplete forms will be rejected.
- Attach copies of all supporting clinical information (progress notes, consults, labs, imaging, operative reports).
Incomplete Submission Risk
Incomplete submissions or missing supporting information may be rejected or result in a delayed determination. Ensure the form is complete and all requested clinical records are provided to avoid denial or processing delays.
- Incomplete forms will be rejected — re‑submission will be required and may delay care.
- Lack of clinical information may result in delayed determination or denial of authorization.
Key Definitions
Admission-Level Criteria by Setting
SNF | LTACH | IRF | hospital inpatient
Admission authorization required for the following inpatient settings when ALL of the following are met:
Service type selected from form list
Criteria for Continued Hospital Inpatient Stays
hospital inpatient — continued stay
Continued stay (concurrent) review requirements for hospital inpatient stays:
Fax concurrent requests to the concurrent requests fax as listed on the form
Discharge Considerations
The discharge date should be provided on the authorization form. If a discharge date is not provided, the length of stay will be determined based on medical necessity. Providers must include copies of supporting clinical documentation to justify the discharge timing; missing clinical information may delay the determination.
Policy Scope and Purpose
This policy governs the administrative requirements for submitting prior authorization requests for Medicare inpatient admissions and related facility settings. It is intended to specify the information and documentation providers must supply (for example, completed form fields and supporting clinical records) to enable the plan to review medical necessity and process determinations. It does not provide clinical treatment guidance; clinical decisions remain the responsibility of the treating provider and must be supported by the clinical records submitted with the authorization request.
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