PA contact and resources

For Behavioral Health Residential Care and other PA inquiries visit the payer PA guidance pages and use the contact channels below.

• PA guidance and forms: www.azblue.com/aca-standardhealth-health-choice/providers/pa-guidelines
• Provider manual (Chapter 6 Authorizations & Notifications): www.azblue.com/aca-standardhealth-health-choice/providers/provider-manual
• Behavioral Health Residential Care fax: 480-760-4732

General PA directives

Follow the general PA directives for ACA StandardHealth with Health Choice: submit required assessments, limit one service per form, confirm member eligibility, and note authorization validity and out-of-network requirements.

• Submit Maternal High Risk Assessment with PA requests
• Only one medical or pharmacy service may be requested per PA form
• Member must be enrolled in ACA StandardHealth with Health Choice at time of service
• Authorizations are valid for 90 days from date issued
• All out-of-network providers/facilities require prior authorization for all services

PA required services list (partial)

Obtain prior authorization for the extensive list of services and CPT/HCPCS codes shown in the grid — ECT and rTMS are explicitly listed examples requiring PA.

• ECT and rTMS are listed as codes that require PA
• See the imaging/procedure code list at the end of the file for the full enumerated list

PA for non-participating providers

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

• PA required for all non-participating providers and hospitals (applies to listed codes)

DME PA threshold

A single DME item with allowed charges over $500 and 'By Report' codes trigger the requirement to obtain prior authorization.

• Examples of DME/E-codes referenced: E2627, K0868, K0886; see grid for complete list

Cosmetic/plastic procedures PA

Prior authorization is required for the listed cosmetic, plastic and esthetic procedures; the grid explicitly names examples that require PA.

• Examples requiring PA: collagen injections, rhinoplasty, otoplasty, scar revision, keloid treatments, surgical repair of gynecomastia, pectus deformity, mammoplasty, abdominoplasty, dermabrasion, Botox injections, vein ligation/ablation

DME & diabetic supplies PA

Durable medical equipment (DME) and diabetic supplies listed on the grid require prior authorization; specific HCPCS/E-codes are identified in the document.

• DME and diabetic supplies are listed as requiring PA (see E0642, E1030, E2301 and other E/K codes in grid)

Genetic testing / experimental PA

Genetic testing CPT codes and certain experimental/investigational procedure codes identified in the grid require prior authorization.

• Multiple genetic testing codes (e.g., ranges such as 81163–81540 and many specific CPT codes) are listed as PA-required

General prior authorization requirement

The grid states that prior authorization is required for listed services and codes — 'PA Required for all Services' appears as a provision in the document.

• Providers must obtain PA for services and codes listed on the PA grid unless an explicit exception applies

Inpatient admission notification

All facilities must notify HCS of inpatient admissions; the document provides a fax number for inpatient notifications.

• Fax inpatient notifications to: 480-760-4732

Performer specialty restriction for nerve conduction studies

Nerve conduction studies may only be performed by Neurologists or Physical Medicine & Rehabilitation physicians; the document notes no prior authorization is required for these studies when performed by those specialists.

• Performer restriction: only Neurologists and Physical Medicine & Rehab Physicians may perform nerve conduction studies
• No PA required for nerve conduction studies when performed by those specialists

EEG and Out-of-Network PA requirement

EEG testing codes (including 95722–95726) require prior authorization when performed in Ambulatory Surgery Centers and when billed by non‑participating providers or hospitals.

• EEG CPT codes listed: 95722, 95723, 95724, 95725, 95726
• PA applies in Ambulatory Surgery Center (Place of Service 24) and for Out‑of‑Network/Non‑Par providers (excluding emergency services)

Genetic testing / Neurologic devices PA requirement

Prior authorization is required for genetic testing, neurologic stimulation devices, and numerous nerve-related procedure codes as listed in the grid.

• Neurologic stimulation devices and associated genetic testing CPT codes are listed as PA-required in multiple sections

Out-of-network PA provisions

For Out‑of‑Network / Non‑Participating providers and facilities, prior authorization is required for the listed codes on the PA grid; emergency services are excluded from this requirement.

• PA is required for listed codes for Out of Network / Non Par Providers & Facilities
• Exclusion: emergency services are not subject to the out‑of‑network PA requirement

Prior authorization required

The grid enumerates numerous procedure and supply codes (CPT, HCPCS, L‑codes) that require prior authorization; obtain PA before service delivery for listed codes.

• Examples include EEG-related codes (95990, G0260), multiple L‑codes for prosthetics/orthotics, and many CPT/HCPCS entries shown in the grid

EEG Prior Authorization

EEG testing codes are listed repeatedly in the grid as requiring prior authorization; PA is required for listed EEG codes and for services delivered by non‑participating providers.

• EEG series (e.g., 95722–95726) are cited as PA-required

Prosthetics/Orthotics Prior Authorization

Prior authorization is required for prosthetics, orthotics, and many L‑ and S‑HCPCS codes listed on the grid; follow the grid guidance when submitting requests.

• Examples of L‑codes listed: L2280, L2310, L3250 and numerous additional L‑ and S‑codes; see grid for full list

Imaging prior authorization via eviCore

Authorizations for MRI, MRA, CT and PET must be obtained through eviCore; requests may be initiated on www.evicore.com or by phone.

• eviCore website: www.evicore.com
• Phone: 888-693-3211 (7am–8pm CST)

PA required for listed services and non-participating providers

Prior authorization is required for the prosthetics/orthotics and therapy CPT/HCPCS codes listed; PA is also required for these services when provided by non‑participating providers or hospitals.

• Physical, occupational, and speech therapy codes shown (e.g., 92507, 97110, 97161) are included on the PA grid
• No PA required for certain therapy services for members under 21 (refer to grid provisions)

Routine office-based procedures exception/statement

Routine office‑based procedures do not require authorization unless otherwise listed on the PA grid; however the grid contains a provision that states 'PA Required for all Services' for specific entries.

• Do not require authorization unless otherwise listed on this grid; check grid entries for exceptions where PA is required

Prior Authorization Requirement and Instructions

Providers should use the BCBSAZ Health Choice PA grid and the payer website to obtain the required PA medical request form and instructions for submission.

• PA medical request form and instructions: www.azblue.com/aca-standardhealth-health-choice/providers/paguidelines
• Specialty medication administration/billing guidance is available on the same site

Synagis PA Exception

Synagis (palivizumab) does not require prior authorization for members under two years of age; providers may obtain Synagis via CVS Caremark Specialty Pharmacy or using 'Buy and Bill'.

• No PA required for Synagis for members < 2 years
• Procurement options: CVS Caremark Specialty Pharmacy or 'Buy and Bill'

PA and billing instructions for specialty medications

Specialty medications administered in contracted provider offices or outpatient facilities require prior authorization and must be billed as a medical claim; indicate 'Buy and Bill' or CVS Caremark options on the PA form when applicable.

• Provider‑administered specialty medications billed as medical claims
• Use 'Buy and Bill' or CVS Caremark Specialty Pharmacy options and indicate on PA request

Synagis PA exception and submission details

For Synagis cases requiring submission (other than the age‑under‑2 exemption), submit a complete Medical PA request form with supporting documentation to the fax number provided in the grid.

• Fax for Medical PA requests (other Synagis cases): 1-877-422-8120
• Include supporting documentation with the Medical PA request form

Prior authorization grid notice

The PA grid is effective 1/26/26 and shows a revision date of 12/10/25; use the grid as the authoritative list of codes that require prior authorization.

• Grid effective date: 1/26/26
• Grid revision date: 12/10/25

Code listing (no prior auth rules in segment)

The HCPCS J‑ and Q‑code listing in this section is provided for billing and drug reference; this segment does not include additional authorization rules.

• J/Q code list and drug names are included for billing reference only; no new PA rules in this listing