Blue Cross Blue Shield AZ Prior Auth Grid

Provider Responsibilities and Submission Requirements

Prior Authorization

General prior authorization requirements

Submit Maternal High Risk Assessment. Only one Medical/Pharmacy service may be requested per PA form. The member must be eligible and a member of ACA StandardHealth with Health Choice at the time the covered service is rendered. Authorizations are valid for 90 days from the date issued. All out-of-network providers/facilities require prior authorization for all services.

Submit Maternal High Risk Assessment as part of PA submission.
Limit one Medical/Pharmacy service request per PA form.
Verify member eligibility at time of service.
Authorizations expire 90 days from issue date.
Out-of-network providers/facilities require PA for all services.

Prior Authorization

Prior authorization required for listed services and non‑par providers

Prior authorization is required for the services listed on this grid. Prior authorization is required for all non-participating (out-of-network) providers and hospitals for the listed services.

Check the PA grid to determine whether a service requires authorization.
Non-participating providers and hospitals must obtain PA for listed services.

Documentation Required

Behavioral health residential PA submission and references

Behavioral health residential care requests must be submitted by fax to 480-760-4732. For PA forms and additional instructions, refer to the online grid and the ACA StandardHealth with Health Choice Provider Manual, Chapter 6: Authorizations and Notifications.

Fax behavioral health residential care requests to 480-760-4732.
See the PA grid online and Provider Manual Chapter 6 for authorization forms and details.

Prior Authorization

PA required for listed procedure codes (e.g., 157xx series)

Prior authorization is required for the specific CPT/procedure codes listed (examples include codes in the 157xx series) and applies to all non‑participating providers and hospitals.

Review the grid for the full list of CPT/procedure codes requiring PA.
Obtain PA for listed codes when services are provided by non‑participating providers/facilities.

Prior Authorization

Procedure codes requiring prior authorization

Prior authorization is required for the procedure codes shown on the grid (examples include 54150, 54160–54164) and is required for all non‑participating providers and hospitals.

Obtain PA for the listed procedure CPTs before rendering services.
Non‑participating providers and hospitals must secure PA for these codes.

Prior Authorization

DME and diabetic supplies: prior authorization and $500 threshold

Durable medical equipment (DME) and diabetic supplies listed (multiple HCPCS/K/E codes such as E0265, E0300, E0460, E0642 and many E/K codes) require prior authorization. Any single DME item with billed charges over $500 requires prior authorization.

PA required for listed DME/diabetic supply HCPCS and K/E codes on the grid.
If billed charges for a single DME item exceed $500, submit a PA request.

Prior Authorization

Specialty and procedure categories requiring PA

The grid includes multiple specialty and procedure categories (Advanced Imaging & Cardiac Imaging, Bariatric Surgery, Behavioral Health, etc.) with associated codes that require prior authorization.

Refer to the grid sections for Advanced Imaging, Cardiac Imaging, Bariatric Surgery, Behavioral Health and other specialty areas for specific PA code requirements.
Obtain PA for services in these specialty categories when codes are listed.

Prior Authorization

Bone growth stimulator HCPCS codes require PA

Prior authorization is required for listed bone growth stimulator HCPCS codes (examples include K1007, K1009, K1015, K0880, A4638, K0885). PA also applies to all non‑participating providers and hospitals.

Submit PA for bone growth stimulator HCPCS codes shown on the grid.
Non‑participating providers/facilities must obtain PA for these items.

Prior Authorization

DME code A9276 and imaging PA provisions; $500 DME rule

PA is required for DME code A9276 and for the listed imaging/procedure codes; additionally, any single DME item with billed charges over $500 triggers a PA requirement.

Submit PA for A9276 when applicable.
DME items billed over $500 require prior authorization.

Prior Authorization

EEG and related neurology codes require PA

Prior authorization is required for neurology EEG testing and related CPT/HCPCS entries (including codes in the 9572x–9572x series). PA is required for the listed EEG codes and associated services.

Obtain PA for EEG CPT/HCPCS codes listed (e.g., 95721–95726).
PA is required for listed codes and for services referenced in these entries.

Prior Authorization

Pain management procedures and injections require PA

A broad set of pain management CPT codes require prior authorization, including injection, infusion and spinal procedure codes (examples: 20552, 20553, 27096, 62320–62327 and related CPTs). This includes initial/new consults, neurotomies, injections, infusions, blocks, pumps/implants and acupuncture.

Submit PA for the pain management CPTs listed prior to providing services.
PA covers a wide range of interventional pain procedures and related services as specified.

Prior Authorization

Prosthetics/Orthotics L‑codes require prior authorization

An extensive set of prosthetics and orthotics L‑codes require prior authorization (sample listed codes include L0112, L0170, L0220, L0456, L0480, L0624, L0638, L1000, L1085, L1250, L1710, etc.). PA is required for the listed L‑codes.

Refer to the prosthetics/orthotics L‑code lists in the grid and submit PA for those L‑codes.
Check the grid for the full list of L‑codes requiring authorization.

Prior Authorization

Place of service and network status PA rules

Prior authorization rules apply by place of service: services at Outpatient Hospital (POS 22) and Ambulatory Surgery Center (POS 24) require PA when listed, and PA is required for out‑of‑network/non‑participating providers and facilities; emergency services are excluded.

Confirm place of service; obtain PA for listed services at POS 22 and POS 24 when required.
Out‑of‑network/non‑participating providers and facilities must obtain PA for listed services; emergency services are excluded from PA requirements.

Prior Authorization

General PA requirement for listed services and non‑par providers

Prior Authorization is required for the services and codes listed throughout this grid; prior authorization is also required for all non‑participating providers and hospitals for these services.

Check the PA grid to confirm whether a service or code requires authorization.
Non‑participating providers and hospitals must obtain PA for listed items.

Prior Authorization

Prosthetics/Orthotics services require PA

Prosthetics and orthotics services identified by multiple L‑code groups require prior authorization as indicated throughout the grid.

Submit PA for prosthetics/orthotics L‑codes listed in the grid.
Refer to the prosthetics/orthotics sections for specific L‑code groupings.

Prior Authorization

Specific prosthetics/orthotics L‑codes require PA

Prior authorization is required for the prosthetics/orthotics L‑codes listed in the grid (examples include L5984, L3230, L3250, L3251, L3252, L3253, L3265, L6020, L6055).

Obtain PA for the specific L‑codes shown before ordering or furnishing devices.
Verify authorization requirements for non‑participating providers/facilities.

Prior Authorization

Additional prosthetics/orthotics L‑codes require PA

Additional prosthetics/orthotics L‑codes and related device codes (examples include L8046, L8047, L8609, L8610, L8612, L8613, L8659, L8627, 69728) require prior authorization as listed.

Submit PA requests for the additional L‑codes and related codes indicated on the grid.
Check the grid for any provider/facility applicability notes.

Prior Authorization

Rehabilitation therapies and cardiac/pulmonary rehab require PA (60‑visit limit)

Cardiac and pulmonary rehabilitation and other rehabilitation therapy CPT/HCPCS codes require prior authorization; a 60 rehabilitative visit limit per year applies to cardiac & pulmonary rehab.

Obtain PA for cardiac & pulmonary rehab and listed rehabilitation therapy CPT/HCPCS codes.
Note the 60‑visit per year limit for cardiac & pulmonary rehabilitation.

Prior Authorization

Routine office‑based procedures require PA

Routine office‑based procedures listed (examples: 97167, 97168, G0237, G0238, G0422–G0424, S9152) require prior authorization as shown on the grid.

Submit PA for the routine office‑based procedure CPT/HCPCS codes listed on the grid.
If a code is not listed on the grid, it does not require authorization unless otherwise specified.

Prior Authorization

PA for routine office procedures and prosthetics/orthotics

Prior authorization is required for the routine office‑based procedure codes and for the listed prosthetics/orthotics codes when shown together on the grid; PA is required for all non‑participating providers and hospitals.

When routine office procedures and prosthetics/orthotics L‑codes are listed, secure PA for both as applicable.
Non‑participating providers/facilities must obtain PA for these listed items.

Prior Authorization

PA provisions for routine office‑based procedure codes

PA is required for the listed routine office‑based procedure codes; codes not listed on the grid do not require authorization unless otherwise specified in the grid provisions.

Do not assume authorization is required for codes not present on the PA grid.
Follow the grid provisions for exceptions and specifics.

Prior Authorization

Skin substitutes (Q4100–Q4303) require PA

Prior authorization is required for all skin substitute services; PA applies to the listed Q‑codes in the Q4100–Q4303 range.

Submit PA for skin substitute products coded Q4100 through Q4303.
PA is required for all skin substitute services listed.

Prior Authorization

Inpatient admissions require PA and facility notifications

All non‑emergency inpatient admissions (acute, rehabilitation, LTAC, SNF, hospice, observation) require prior authorization. Facilities must notify HCS and fax inpatient notifications to 480-760-4732. For emergency admissions used to evaluate and stabilize, the plan must be notified within 1 calendar day.

Fax inpatient notifications to 480-760-4732 to notify HCS of admissions.
For emergency stabilization admissions, notify the plan within one calendar day.

Prior Authorization

High‑tech imaging and select procedures require PA

High‑tech imaging and select procedures (MRI, MRA, CT, PET, certain ultrasounds, nuclear cardiac stress testing, echocardiography TEE/TTE, cardiac catheterizations, venous ablation) require prior authorization; some services may be considered experimental, investigational, or unproven.

Obtain PA for high‑tech radiology services and the listed imaging/procedure CPTs.
Be aware that certain services may be considered EIU and subject to additional review.

Prior Authorization

All grid codes require PA — use StandardHealth resources

All codes listed on the PA grid require prior authorization from ACA StandardHealth with Health Choice. Visit the StandardHealth website for the PA medical request form and additional PA information.

Use https://www.standardhealthhc.com to access the PA medical request form and PA guidance.
Ensure PA is obtained for any code shown on the grid prior to service delivery as required.

Documentation Required

Specialty medication PA submission and billing requirements

Provider‑administered specialty medications must have a complete Medical PA request form submitted with supporting documentation to fax 1-877-422-8120. Provider‑administered specialty medications must be billed as a medical claim.

Submit the complete Medical PA request form and supporting documentation to fax: 1-877-422-8120.
Bill provider‑administered specialty medications as medical claims after PA is obtained.

Documentation Required

Specialty medication code listings for PA and billing

The document contains a reference list of specialty medications and associated HCPCS/J‑ and Q‑codes to be used for authorization and claims processing; consult the list for the exact billing codes required when submitting PAs.

Use the specialty medication code lists (J‑ and Q‑codes) in the grid when preparing PA submissions and claims.
Ensure the correct HCPCS/J/Q code is included on the PA request for provider‑administered medications.

Documentation Required

Specialty medication code reference (partial)

This section provides a partial reference list of specialty medications and their HCPCS/J‑ and Q‑codes for authorization and billing workflows; use these codes when submitting medical PA requests for specialty agents.

Refer to the listed J‑ and Q‑codes (e.g., J9299, J9999, J2326) when preparing PA requests for specialty medications.
Confirm PA and billing requirements per the grid and Provider Manual.

Key Terms and Definitions

Prior Authorization

DefinitionPrior Authorization (PA) — authorization issued for a requested service that is valid for 90 days from the date issued.

Provider responsibilityMember must be eligible at time of service; out-of-network providers/facilities require PA for all services.

Form rulesOnly one Medical/Pharmacy service may be requested per PA form (per submission guidance).

ASH chiropractic network

Network administrationAmerican Specialty Health (ASH) musculoskeletal networks contract administers chiropractic services for most AZ Blue commercial benefit plans.

ScopeApplies to ASH-administered musculoskeletal network services referenced in the PA grid.

Reference noteSee imaging/procedure code list and PA provisions for related service entries.

PA required for listed codes and for all non-participating providers and hospitals

RequirementPrior Authorization is required for the listed codes and for all non-participating providers and hospitals.

Applies toAll CPT/HCPCS/procedure codes enumerated in the grid and services rendered by non-participating providers/facilities.

ExceptionEmergency services are excluded where specifically noted in provisions.

Imaging/procedure code list reference

Where to find listSee the IMAGING / PROCEDURE code list at the end of this file for high‑tech radiology and related procedure CPTs requiring PA.

IncludesMRI, MRA, CT, PET, specialized ultrasounds, nuclear cardiac testing, echocardiography, cardiac catheterizations, venous ablation procedures.

NoteSome services listed may be considered Experimental, Investigational or Unproven (EIU).

Prior Authorization (PA)

ScopePrior Authorization is required for the procedure codes, DME and diabetic supplies listed in the grid.

DME thresholdDME items with billed charges over $500 for a single item require PA.

Network notePA requirement emphasized for non‑participating providers and hospitals.

DME over $500

DefinitionDME over $500 — any durable medical equipment item with billed charges exceeding $500 triggers a prior authorization requirement.

ExamplesMultiple HCPCS/E-codes listed in the grid (e.g., E0265, E0642, A9276) are subject to DME provisions and the $500 threshold.

Action for providersObtain PA before rendering or billing DME items expected to exceed $500 per single item.

Non-par providers/facilities

DefinitionNon-par providers/facilities — non-participating (out-of-network) providers and hospitals are subject to PA requirements in this grid.

Place of servicePA rules apply to specified places of service (e.g., Outpatient Hospital POS 22, Ambulatory Surgery Center POS 24) and out-of-network settings.

Emergency exclusionEmergency services are excluded from PA requirements unless otherwise specified.

Emergency services exclusion

ExclusionEmergency services are excluded from prior authorization requirements where the provisions state 'Excluding Emergency services.'

ContextApplies to out-of-network/non-par provider entries where emergency care is explicitly excepted.

Provider actionFor emergency admissions, notify plan per facility notification rules (see inpatient services provisions).

Prior Authorization requirement

Requirement summaryPrior Authorization is required for all non-participating providers and hospitals for the services and codes listed in this section.

Applies toAll listed CPT/HCPCS/procedure codes; non-par providers must obtain PA prior to services unless emergency.

ReferenceSee the code lists and provisions throughout the grid for specific code requirements and exceptions.

All codes listed on the grid require prior authorization

General ruleAll codes listed on the grid require prior authorization from ACA StandardHealth with Health Choice.

Where to get formsVisit https://www.standardhealthhc.com for the PA medical request form and more information on prior authorization requirements.

Submission instructionUse the Medical PA request form and include supporting documentation as specified in the form instructions.

Prior Authorization (PA)

ScopePrior Authorization is required for the procedure codes, DME and diabetic supplies listed and for specialty medications per the grid.

Specialty meds billingProvider‑administered specialty medications must be billed as a medical claim; PA must be obtained when required.

Submission faxSubmit a complete Medical PA request form with supporting documentation to fax: 1-877-422-8120.

DME over $500

DefinitionAny durable medical equipment item with billed charges exceeding $500 per single item triggers a prior authorization requirement.

Policy locationsThis provision is repeated in DME/diabetic supplies sections and DME-specific code blocks throughout the grid.

Provider actionObtain PA before ordering or billing DME expected to exceed the $500 single‑item charge threshold.

Non-par providers/facilities

DefinitionNon-participating providers and hospitals — providers/facilities outside the network for which PA is required for listed services.

ApplicabilityPA requirement explicitly applies to non‑par providers/facilities for all listed codes and services in the grid.

Place of service noteOutpatient Hospital (POS 22) and other specified POS entries are included under PA rules for non‑par providers.

Prior Authorization requirement

RequirementPrior Authorization is required for all non-participating providers and hospitals for the services and codes listed; emergency services excluded where noted.

Provider actionNon‑par providers must secure PA prior to performing listed services unless an emergency exemption applies.

ReferenceSee grid entries and provisions for service‑specific requirements and exceptions.

60 rehabilitative visits per year for cardiac & pulmonary rehabilitation

Limit60 rehabilitative visits per year applies to cardiac and pulmonary rehabilitation and requires prior authorization.

Applies to codesCardiac & pulmonary rehab and related rehabilitation CPT/HCPCS codes listed in the grid (e.g., G0237, G0238).

Provider actionRequest PA for rehab services and track visit counts against the 60 visits/year limit.

Experimental, Investigational or Unproven (EIU)

DefinitionExperimental, Investigational or Unproven (EIU) — services that may be considered EIU as noted in imaging/procedure entries.

ContextCertain high‑tech imaging and procedures may be flagged as EIU in the grid; check specific entries for determination.

ActionVerify EIU status in the grid when seeking PA for listed imaging/procedure services.

J0129	Abatacept, 10 mg (Orencia)
J0586	AbobotulinumtoxinA, 5 units (Dysport)
J0135	Adalimumab, 20 mg (Humira)
Q5131	Adalimumab-aacf, biosimilar (Idacio)
Q5132	Adalimumab-afzb, biosimilar, 10 mg (Abrilada)
J9354	Ado-trastuzumab emtansine, 1 mg (Kadcyla)
J0172	Aducanumab-avwa, 2 mg (Adulhelm)
J7352	Afamelanotide implant, 1 mg (Scenesse)
J0178	Aflibercept, 1 mg (Eylea)
J0180	Agalsidase beta, 1 mg (Fabrazyme)

OpenPayer

Prior Authorization Grid for ACA StandardHealth with Health Choice

Prior Authorization Coverage Criteria

Codes and Procedure Listings Requiring Prior Authorization

Provider Responsibilities and Submission Requirements

Key Terms and Definitions