ModifiedArizona Health Care Cost Containment SystemPolicy N/A

AHCCCS Prior Authorization (PA) and Concurrent Review (CR) Standards during COVID-19 Emergency for Fee-for-Service Health Programs

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Temporary AHCCCS prior authorization, concurrent review, pharmacy, facility, transportation, home health, and durable medical equipment requirements during the COVID-19 public health emergency for Fee-for-Service members and providers.

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyAHCCCS Prior Authorization (PA) and Concurrent Review (CR) Standards during COVID-19 Emergency for Fee-for-Service Health Programs

Policy CodePolicy N/A

Change TypeModified

Effective DateJune 1, 2021

Next Review DateN/A

Key ActionBeginning June 15, 2021, resume applicable pharmacy utilization management edits and prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

Effective June 15, 2021, pharmacy flexibility provisions in Sections III.A and III.B ended and prior utilization management edits and prior authorization requirements were reinstated.

Physical health facility services temporarily continued without prior authorization and concurrent review for specified levels of care for dates of service from August 1 through August 20, 2021.

Beginning August 1, 2021, outpatient prior authorization approvals were no longer automatically extended, although DFSM could grant a six-month extension when needed.

COVID-19 testing, diagnosis, and treatment services do not require prior authorization or concurrent review.

90 days

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ModifiedArizona Health Care Cost Containment SystemPolicy N/A

AHCCCS Prior Authorization (PA) and Concurrent Review (CR) Standards during COVID-19 Emergency for Fee-for-Service Health Programs

Customize your policy alerts

Sign up for all Arizona Health Care Cost Containment System policy alerts

Know when Arizona Health Care Cost Containment System releases new policies or updates existing guidance.

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Policy Summary

PayerArizona Health Care Cost Containment System

PolicyAHCCCS Prior Authorization (PA) and Concurrent Review (CR) Standards during COVID-19 Emergency for Fee-for-Service Health Programs

Policy CodePolicy N/A

Change TypeModified

Effective DateJune 1, 2021

Next Review DateN/A

Key ActionBeginning June 15, 2021, resume applicable pharmacy utilization management edits and prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

Effective June 15, 2021, pharmacy flexibility provisions in Sections III.A and III.B ended and prior utilization management edits and prior authorization requirements were reinstated.

Physical health facility services temporarily continued without prior authorization and concurrent review for specified levels of care for dates of service from August 1 through August 20, 2021.

Beginning August 1, 2021, outpatient prior authorization approvals were no longer automatically extended, although DFSM could grant a six-month extension when needed.

COVID-19 testing, diagnosis, and treatment services do not require prior authorization or concurrent review.

90 days

Residential treatment center concurrent review

6 monthsPotential authorization extension

1 kit/monthAt-home COVID-19 testing allowance

12 monthsFace-to-face encounter deadline

100 milesNEMT distance threshold

June 15, 2021Pharmacy flexibility end date

General and Service-Specific Coverage Rules

General Reimbursement and Emergency Standards

All services reimbursed under these emergency standards must satisfy the applicable coverage and reimbursement requirements.

ALL of the following

The service is medically necessary.
The service is cost-effective.
The service is federally reimbursable.
The service is state reimbursable.
The service remains subject to post-payment review.
The applicable temporary prior authorization and concurrent review standards are followed for the AHCCCS Division of Fee-for-Service Management (DFSM) population, including the American Indian Health Program (AIHP), Tribal Regional Behavioral Health Authorities (TRBHAs), and Tribal Arizona Long Term Care Services (Tribal ALTCS).

EMERGENCY-TEMPORARY CONDITIONS

The service is provided during the COVID-19 public health emergency and is governed by the temporary standards in this section.
The standards are subject to change as emergency conditions evolve and apply through the duration of the emergency unless otherwise specified.
The service qualifies for a service-specific temporary waiver, extension, or modified authorization requirement described below.

Service-Specific Temporary Rules

The following temporary rules apply to the identified service categories and dates. Unless a specific exception applies, services remain subject to medical necessity, reimbursement, and post-payment review requirements.

BEHAVIORAL HEALTH SERVICES

For non-emergency Behavioral Health Inpatient, Residential Treatment Center (RTC), and Behavioral Health Residential Facility (BHRF) levels of care, initial prior authorization is obtained.
Initial prior authorization remains required.
For RTC levels of care, concurrent review may be extended from 30 days to 90 days.
Clinical Staffings, Child and Family Teams (CFTs), Adult Recovery Teams (ARTs), and coordination of care between facilities and outpatient providers should continue to inform the appropriate level of care and continued stay. Telehealth and telephonic modalities are strongly encouraged.

DENTAL SERVICES

A dental prior authorization approval that is within 60 days of expiration may be extended for 6 months.

COVID-19 TESTING AND TREATMENT

Operational Timeframes and Thresholds

Residential Treatment Center Review

Concurrent review period90 days for Residential Treatment Center levels of care

Initial authorizationStill required for non-emergency Behavioral Health Inpatient, Residential Treatment Center, and Behavioral Health Residential Facility levels of care

Continued-stay supportClinical Staffings, Child and Family Teams, Adult Recovery Teams, and coordination between facilities and outpatient providers should inform level-of-care and continued-stay decisions

Dental Authorization Expiration

Affected approvalsDental prior authorization approvals

Expiration windowApprovals within 60 days of expiration qualify

Authorization, Pharmacy, and Service Requirements

Prior Authorization

Behavioral Health Initial Authorization

Obtain initial prior authorization for non-emergency behavioral health inpatient, Residential Treatment Center (RTC), and Behavioral Health Residential Facility (BHRF) levels of care.

Applies to initial authorization; emergency behavioral health services are not included.
DFSM plans to extend RTC concurrent reviews from 30 to 90 days.

Note

Behavioral Health Continued-Stay Coordination

Continue using clinical staffings, Child and Family Teams (CFTs), Adult Recovery Teams (ARTs), and coordination between facilities and outpatient providers to determine appropriate levels of care and support continued stays.

Telehealth and telephonic modalities are strongly encouraged for staffings and care coordination.

Unsupported block type: prior_auth

Program and Encounter Definitions

Fee-for-Service Health Programs

American Indian Health ProgramIncluded in AHCCCS Fee-for-Service programs

Tribal Regional Behavioral Health AuthoritiesIncluded in AHCCCS Fee-for-Service programs

Tribal Arizona Long Term Care ServicesIncluded in AHCCCS Fee-for-Service programs

Face-to-Face Encounter

Required encounterA provider face-to-face encounter required for initiation of home health services and medical equipment or supplies under 42 CFR 440.70

Emergency-period timingDuring the COVID-19 emergency, the encounter does not need to occur before services begin

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyAHCCCS Prior Authorization (PA) and Concurrent Review (CR) Standards during COVID-19 Emergency for Fee-for-Service Health Programs

Policy CodePolicy N/A

Change TypeModified

Effective DateJune 1, 2021

Next Review DateN/A

Key ActionBeginning June 15, 2021, resume applicable pharmacy utilization management edits and prior authorization requirements.

SourceLink

On This Page

Prior authorization and concurrent review are not required for services related to COVID-19 testing, diagnosis, and/or treatment.
One at-home COVID-19 testing kit containing two tests is covered when filled at a pharmacy with a prescription, limited to one kit per member per month.

FACILITY SERVICES

For dates of service from 8/1/2021 through 8/20/2021, prior authorization and concurrent review requirements are temporarily removed for acute inpatient hospitalization, assisted living facilities/centers, skilled nursing facilities (SNFs), and inpatient rehabilitation facilities, including long-term acute care hospitals.
The memo describes this as a continued temporary removal of requirements.
FFS providers coordinate care management activities to ensure safe and effective transitions between levels of care.
A prior authorization approval for elective inpatient services that is within 60 days of expiration may be extended for 6 months, as needed.

OUTPATIENT SERVICES

Effective 8/1/2021, outpatient service prior authorization approvals within 60 days of expiration are no longer automatically extended.
When additional prior authorization is needed, the provider submits the prior authorization request.
DFSM may extend an outpatient service prior authorization approval within 60 days of expiration for 6 months, as needed.
For COVID-19 emergency services other than testing, diagnosis, and treatment, the prior authorization document-submission period is not extended to 90 days.
COVID-19 testing, diagnosis, and treatment are exempt from prior authorization; see the COVID-19 testing and treatment rule above.

NON-EMERGENCY MEDICAL TRANSPORTATION

Effective 8/1/2021, a non-emergency medical transportation (NEMT) provider transporting a member more than 100 miles obtains prior authorization.
NEMT providers may temporarily waive the requirement to collect the passenger's signature, whether on paper or electronically.
The source also states that prior authorization requirements for NEMT services over 100 miles were temporarily waived; providers should reconcile this statement with the effective 8/1/2021 requirement before billing.

HOME HEALTH SERVICES AND DURABLE MEDICAL EQUIPMENT

For initiation of home health services and medical equipment and supplies for the FFS population, the face-to-face encounter does not need to be completed before services start.
CFR § 440.70 ordinarily requires a face-to-face encounter. CMS temporarily approved an extension under section 1135(b)(5) of the Social Security Act.
The face-to-face encounter occurs at the earliest feasible time for the provider and no later than 12 months from the start of service.<= 12 months from start of service
The temporary extension applies effective 6/8/2020 through the duration of the emergency.
All home health services and durable medical equipment services remain subject to post-payment review.

Applicable actionQualifying approvals will be extended for six months

Potential Authorization Extension

Dental approvalsDental prior authorization approvals within 60 days of expiration will be extended for six months

Elective inpatient approvalsPrior authorization approvals within 60 days of expiration may be extended for six months, as needed

Outpatient approvalsDFSM may extend outpatient prior authorization approvals within 60 days of expiration for six months, as needed

At-Home COVID-19 Testing

Monthly allowanceOne at-home COVID-19 testing kit per member per month

Tests per kitEach kit contains two tests

Dispensing requirementThe kit must be filled at a pharmacy with a prescription

NEMT Distance Threshold

Distance thresholdTransportation over 100 miles

Prior authorization instructionEffective August 1, 2021, NEMT providers transporting a member over 100 miles must obtain prior authorization

Temporary waiverPrior authorization requirements for NEMT services over 100 miles were temporarily waived

Face-to-Face Encounter Deadline

Completion deadlineThe face-to-face encounter must occur within 12 months from the start of service

Timing flexibilityThe encounter does not need to be completed before services begin and may occur at the earliest time feasible for the provider

Review requirementHome health, medical equipment, and supply services remain subject to post-payment review

Prior Authorization

Pharmacy Flexibility Termination

Beginning June 15, 2021, the temporary pharmacy flexibilities in Sections III.A and III.B end. Reinstitute the utilization-management edits and prior authorization requirements that applied under the previous plan setups, and transition applicable non-grandfathered non-preferred medications to preferred agents.

Agents designated as preferred on the AHCCCS Drug List apply.
IHS and 638 pharmacies may continue billing 90-day maintenance medication supplies when billing the All-Inclusive Rate.
Specialty medication fills return from 60 days to 30 days.

Billing Rule

Temporary Pharmacy Utilization-Management Relief

During the stated temporary flexibility period, remove specified refill-too-soon edits and permit qualifying early fills while confirming that quantity-limit and duplicate-therapy edits do not reject appropriately overridden claims.

Remove refill-too-soon edits for all non-controlled medications; members may fill up to 30-day supplies or 90-day maintenance medication supplies early.
Thirty-day specialty medications delivered to the member's home may be filled early for the same day's supply as the prior fill.
Controlled substances may be refilled early only after pharmacy staff confirm prescriber agreement; pharmacy staff or the prescriber must contact the health plan PBM help desk for an immediate override.
Remove prior authorization requirements for antibiotics; antimalarials; antivirals; beta2 agonist inhalers and inhalant solutions; long-acting beta2 agonist-corticosteroid and beta2 agonist-anticholinergic combination inhalers; corticosteroid inhalers, inhalant solutions, and oral agents; nebulizers available through pharmacies; cough and cold products; antihistamines; nasal decongestants; antihistamine/nasal-decongestant combinations; cough suppressants including guaifenesin and combination products; guaifenesin oral tablets and combination products; analgesic/antipyretic products; mast cell stabilizers; and methylxanthines.

Unsupported block type: prior_auth

Prior Authorization

Facility Service Temporary Relief

For dates of service from August 1 through August 20, 2021, remove prior authorization and concurrent review requirements for specified facility levels of care and coordinate care management to support safe, effective transitions between levels of care.

Applies to acute inpatient hospitalization, assisted living facilities or centers, skilled nursing facilities, and inpatient rehabilitation facilities, including long-term acute care hospitals.
Prior authorization approvals for elective inpatient services within 60 days of expiration may be extended for six months, as needed.

Prior Authorization

Outpatient Authorization Submissions

Effective August 1, 2021, outpatient service prior authorization approvals within 60 days of expiration are no longer automatically extended. Providers must submit a prior authorization request when additional authorization is needed.

DFSM may extend outpatient approvals within 60 days of expiration for six months, as needed.
For COVID-19 emergency services other than testing, diagnosis, and treatment, the prior authorization document-submission period is no longer extended to 90 days.
COVID-19 testing, diagnosis, and treatment remain exempt from prior authorization; see the COVID-19 services exemption.

Prior Authorization

NEMT Distance Authorization Instructions

Effective August 1, 2021, NEMT providers transporting a member more than 100 miles must obtain prior authorization.

The temporary waiver of prior authorization requirements for NEMT services over 100 miles ends under this instruction.
The requirement for NEMT drivers to collect a passenger signature, on paper or electronically, remains temporarily waived.

Documentation Required

Home Health and Equipment Face-to-Face Timing

For home health services and durable medical equipment or supplies, complete the required face-to-face encounter no later than 12 months from the start of service.

During the emergency, the encounter does not need to occur before services begin and may occur at the earliest feasible time for the provider.
All services remain subject to post-payment review.

The encounter may occur at the earliest feasible time for the provider but must be completed within 12 months from the start of service