Currentblue cross blue shield - arizonaPolicy N/A

BCBSAZ Health Choice Prior Authorization Grid — ACA StandardHealth with Health Choice

Defines prior authorization requirements, contact information, and codes for services requiring PA under the BCBSAZ ACA StandardHealth with Health Choice product; affects participating and non‑participating providers and members of that product.

Policy Summary

Payerblue cross blue shield - arizona

PolicyBCBSAZ Health Choice Prior Authorization Grid — ACA StandardHealth with Health Choice

Policy CodePolicy N/A

Change TypeCodes addedpediatric therapy PA removedheader revision noted

Effective DateApr 10, 2025

Next Review DateN/A

Key ActionObtain prior authorization for listed services and for all non‑participating providers and hospitals; submit required PA form and supporting documentation (authorizations valid 90 days).

SourceLink

POLICY UPDATE CHANGES

Document header shows revision dated 3/10/25 and effective date 4/10/25.

Codes have been added to require prior authorization (lists of medical and pharmacy code mapping shown).

Physical, occupational, and speech therapies no longer require prior authorization for members 20 years old and under.

BCBSAZ Health Choice Prior Authorization Grid effective 4/10/25. Revised 3/10/25.

90 daysauthorization validity period

1-800-322-8670phone

1-877-422-8120medical/fax

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

<2 yrsSynagis exception

Prior Authorization Coverage Criteria

Coverage reference

Coverage reference — This Prior Authorization grid and code list identify services and medications that require prior authorization from BCBSAZ Health Choice. For detailed PA forms, submission instructions, and the complete medication/code lists, refer to the payer resources listed below.

All codes listed on the PA grid require prior authorization from BCBSAZ Health Choice. (See: https://www.azblue.com/health-choice-az)

Specialty medications (injectable, infusion, implants) require PA prior to administration in contracted provider offices or other outpatient settings; they must be billed on a medical claim. 'Buy and Bill' and CVS Caremark Specialty Pharmacy are accepted acquisition/billing options and should be indicated on the PA request form.

SYNAGIS (palivizumab) — no prior authorization required for members under age 2. Providers may use CVS Caremark Specialty Pharmacy or 'Buy and Bill'. A complete Medical PA request form with supporting documentation must be faxed to 1-877-422-8120 when PA is required for other indications.

The PA grid is effective 2025-04-10 (revised 2025-03-10). It includes medical and pharmacy codes (examples include but are not limited to: J0589 for Synagis; J0129 Orencia; J9354 Kadcyla; Q2057 Tecelra; and many additional J-, L-, E-, CPT, HCPCS and DME codes).

Imaging prior authorizations (MRI, MRA, CT, PET) are managed through eviCore; follow eviCore submission processes for those services.

Durable Medical Equipment (DME) and diabetic supplies: a single item with allowed charges over $500 and 'By Report' codes requires prior authorization.

All non-participating providers and all non-participating hospitals require prior authorization for listed services regardless of place of service.

Facility inpatient notification: All acute hospitals (including maternity & delivery), SNF, rehabilitation and LTAC facilities must fax inpatient notifications to 480-760-4732 as indicated in the PA grid.

Codes and Coding Rules Requiring Prior Authorization

Medical Pharmacy code mappings (covered)HCPCSCovered

J1072 -> Q5148/Q5147/Q5150/Q5149/Q5151	J1072 maps to listed Q-codes for equivalent Aflibercept biosimilars/versions.
Q2057 -> J9161/J9038/J9024/J2351/Q9999	Q2057 maps to multiple J-/Q- codes including denileukin diftitox and others.
J1299 -> J1299/Q5152	J1299 listed with mapping to biosimilar Q5152 where applicable; also J1299 remains.

PA Removed (not covered)mixedNot Covered

Pediatric therapies

Physical, Occupational, and Speech therapies — no prior authorization required for members 20 years old and under.

Selected CPT/Procedure codes requiring PA (covered)CPTCovered

15771	Tissue rearrangement procedures — PA required as listed.
15782	PA required.
15783	PA required.
15786	PA required.
15788	PA required.
15820	PA required.
17108	Tattoo removal and related procedures — PA required.
19316	Breast surgery codes — PA required.
19355	Breast procedures — PA required.
19396	Brevision / reconstructive breast surgery — PA required.

1–10 of 18

1/2

E-code DME items requiring PA (covered)HCPCSCovered

E0265	DME item — PA required when single item allowed charges over $500 or as listed.
E0266	DME item — PA required.
E0270	DME item — PA required.
E0300	DME item — PA required.
E0460	DME item — PA required.
E0483	DME item — PA required.
E0620	DME item — PA required.
E0636	DME item — PA required.
E0638	DME item — PA required.
E0641	DME item — PA required.

1–10 of 34

1/4

What Providers Must Do

Prior Authorization

General PA directives — submission & validity

Submit a Maternal High Risk Assessment with the PA request; only one medical or pharmacy service may be requested per PA form. The member must be eligible for ACA StandardHealth with Health Choice at the time the service is rendered and all authorizations are valid for 90 days. All out-of-network providers/facilities require prior authorization.

Submit Maternal High Risk Assessment.
One Medical/Pharmacy service per PA form.
Member must be eligible at time of service.
Authorizations valid for 90 days from date issued.
Out-of-network providers/facilities require PA.

Documentation Required

Behavioral health residential PA contacts & resources

Fax behavioral health residential care requests to 480-760-4732. For PA requirements, the PA grid, and the required authorization forms, providers should visit the ACA StandardHealth with Health Choice PA guidelines page and refer to the Provider Manual Chapter 6 for details.

Key Definitions and Terms

inv-70: PA — Prior Authorization (PA)

PAPrior Authorization (PA).

Definition contextA required approval from BCBSAZ Health Choice before certain services are provided/billed (see grid).

Provider action implicationOut‑of‑network providers/facilities require PA for all services.

inv-71: ASH — American Specialty Health (ASH) musculoskeletal networks are contracted to provide the Arizona network and administer chiropractic services.

ASH roleAmerican Specialty Health (ASH) musculoskeletal networks are contracted to provide the Arizona network and administer chiropractic services for most AZ Blue commercial benefit plans.

ApplicabilityReferenced in the PA grid entries under 'HEALTH = Chiropractor' and specialty/service listings.

Policy Summary

Payerblue cross blue shield - arizona

PolicyBCBSAZ Health Choice Prior Authorization Grid — ACA StandardHealth with Health Choice

Policy CodePolicy N/A

Change TypeCodes addedpediatric therapy PA removedheader revision noted

Effective DateApr 10, 2025

Next Review DateN/A

Key ActionObtain prior authorization for listed services and for all non‑participating providers and hospitals; submit required PA form and supporting documentation (authorizations valid 90 days).

SourceLink

On This Page

Behavioral health residential care requests fax: 480-760-4732.
PA grid and forms available at: https://www.azblue.com/aca-standardhealth-health-choice/providers/pa-guidelines
See Provider Manual, Chapter 6 (Authorizations and Notifications) for PA forms and details.

Prior Authorization

PA required for listed procedure codes (partial list)

Prior authorization is required for the procedure and HCPCS/CPT codes listed in the grid; PA is required for all non‑participating providers and hospitals. The grid contains numerous CPT/HCPCS entries that must be authorized prior to service.

PA is required for listed procedure codes and for all non‑participating providers and hospitals.
See the imaging/procedure code list at the end of the file for full code listings.

Prior Authorization

Prior authorization required — listed services & non‑par providers

Obtain prior authorization for the services and codes listed on the PA grid; prior authorization is explicitly required for all non‑participating providers and hospitals.

Prior Authorization is required for the services and codes listed below.
PA is required for all non‑participating providers and hospitals.

Prior Authorization

DME PA & $500 single‑item threshold

Specific DME and diabetic supply HCPCS codes listed on the grid require prior authorization. Additionally, any single DME item with allowed charges over $500 or 'By Report' codes requires prior authorization.

DME/diabetic supply HCPCS codes on the grid (examples listed in document) require PA.
A single DME item with allowed charges over $500 requires prior authorization.

Prior Authorization

General prior authorization requirement

Prior authorization is required for the services listed on the grid; this requirement applies to all non‑participating providers and hospitals.

PA required for services listed.
PA required for non‑participating providers and hospitals.

Documentation Required

Inpatient notification — fax admissions to HCS

Fax inpatient admission notifications for all Acute Hospitals (including Maternity & Delivery), Skilled Nursing Facilities, Rehabilitation and LTAC facilities to 480-760-4732; all facilities must notify Health Choice Services of admissions.

Fax inpatient notifications to: 480-760-4732.
Applies to All Acute Hospitals (including Maternity & Delivery), SNF, Rehabilitation, LTAC.

Prior Authorization

Code‑group PA — genetic/molecular examples

Multiple genetic/molecular procedure code groupings (examples: 81210, 81222, 81266, 81297 and related codes) require prior authorization when listed; PA applies to all services in these code groups.

Genetic/molecular test codes (e.g., 81210, 81163–81167, 81201–81204) are listed with PA required.
PA stated as 'PA Required for all Services' for these groups.

Prior Authorization

PA & inpatient notification — services listed

Prior authorization is required for the listed services; submit inpatient notifications by fax to 480-760-4732. PA applies to all services listed and facilities must notify HCS of admissions.

PA required for listed services.
Fax inpatient notifications to 480-760-4732.

Documentation Required

Nerve conduction studies — provider qualifications

Nerve conduction studies may only be performed by neurologists or physical medicine and rehabilitation physicians. The entry notes provider qualification and includes a line indicating no PA required in one line but overall PA statements appear elsewhere.

Nerve conduction studies: can only be performed by Neurologists and Physical Medicine and Rehab Physicians.
Document contains conflicting lines noting 'no PA required' for this item while overall PA requirements exist elsewhere.

Prior Authorization

PA required — specialty/procedure services & POS

Prior authorization is required for the listed specialty/procedure/services (examples include codes .95722, .95725, .95726); PA is required for all non‑participating providers and hospitals and Place of Service mappings (e.g., ASC 24) are noted.

PA required for listed specialty/procedure/services (e.g., .95722, .95725, .95726).
Ambulatory Surgery Center (Place of Service 24) and Outpatient Hospital (POS 22) mappings referenced.

Prior Authorization

Codes with PA required — mappings & examples

Multiple code mappings in the grid (examples include 81163–81167, 81201–81204, L8682, 64568) indicate that prior authorization is required for the listed codes and mapped services.

Code mappings (e.g., L8682 with 81163–81167; 64568 mappings) flagged as PA required.
PA Required for all Services noted for these mappings.

Prior Authorization

Neurologic stimulation devices — PA required

Neurologic stimulation device entries show mapping of molecular/genetic codes (e.g., 81163) to procedural code 61850 and indicate that prior authorization is required for neurologic stimulation devices.

81163 mapped to 61850 for Neurologic Stimulation Devices.
PA Required for Neurologic Stimulation Devices.

Prior Authorization

PA required — listed codes & non‑par providers

Prior authorization is required for the listed services and codes; this requirement applies to all non‑participating providers and hospitals. Multiple code mappings and POS references are provided in the grid.

PA required for listed services and for all non‑participating providers and hospitals.
Multiple mappings and Place of Service notes provided in the grid.

Prior Authorization

PA required — listed codes and outpatient/ASC POS

Prior authorization is required for the services and CPT/HCPCS/L-codes listed and for services performed in Outpatient Hospital (POS 22) and Ambulatory Surgery Center (POS 24) settings when indicated.

PA required for listed CPT/HCPCS/L-codes (examples in chunks 108–111).
Place of Service 22 (Outpatient Hospital) and 24 (ASC) noted for many entries.

Prior Authorization

Prior authorization — L0112 and related L‑codes

Additional HCPCS L-code groups (e.g., L0112 and associated L-codes) require prior authorization when performed in outpatient hospital or ambulatory surgery center settings.

L0112 group and related L-codes require PA in Outpatient Hospital/ASC settings.
PA required for non‑participating providers and hospitals.

Prior Authorization

Neurology/EEG & L‑code groups — PA required

Neurology EEG testing and multiple L-code items (examples: L0624, L0629) are listed as requiring prior authorization on the grid.

Neurology EEG testing entries (e.g., L0624) require PA.
Multiple L-code groups listed with PA requirement.

Prior Authorization

Later L‑code groups (L32xx) — prosthetics/orthotics PA

Later L-code ranges (L32xx and related prosthetics/orthotics codes such as L3201–L3221) are included in the prior authorization list and require PA when listed.

L32xx range and prosthetics/orthotics codes (e.g., L3201–L3221) require prior authorization.
PA applies to services in Outpatient Hospital and ASC settings as noted.

Prior Authorization

Prosthetics & orthotics L‑codes — PA required

Extensive prosthetics, orthotics and specialty L-code items (examples: L3251–L3973 range entries) are listed on the grid and require prior authorization when billed.

Prosthetics/Orthotics L-codes (e.g., L3251, L3252, L3253, L3265, L3671) require PA.
PA applies across listed L-code items in the grid.

Prior Authorization

Selected PA entries — EEG & related services

Selected entries (examples: neurology EEG testing codes) require prior authorization; PA is required for all non‑participating providers and hospitals for these services.

Neurology EEG testing entries (e.g., L3213, L0624) require PA.
PA required for all non‑participating providers and hospitals.

Prior Authorization

Therapies & audiology CPTs — PA required

Rehabilitation, therapy and audiology-related CPT codes (examples: 92508, 92521–92526, 97039, 97110) are listed on the PA grid and require prior authorization per the grid.

Therapies & audiology CPTs (e.g., 92508, 92521–92526, 97039, 97110) listed as PA required.
Some therapy codes include contextual notes about routine office-based procedures (see G0423 guidance).

Note

G0423 guidance — routine office procedures exception

G0423 is noted as a routine office‑based procedure that does not require authorization unless otherwise listed on the grid, although the grid context also marks G0423 as 'PA Required for all Services' where applicable.

G0423: Routine office-based procedures do not require authorization unless otherwise listed on this grid.
Grid context includes 'PA Required for all Services' notation for G0423 where applicable.

Prior Authorization

Imaging PA via eviCore — initiation & contact

Prior authorizations for MRI, MRA, CT and PET must be obtained through eviCore; providers may initiate requests by phone at 888-693-3211 or via the eviCore website.

Imaging PA vendor: eviCore.
eviCore phone: 888-693-3211 (7am–8pm CST).
Use eviCore web portal or phone to obtain PAs for MRI/MRA/CT/PET.

Prior Authorization

All grid codes require PA — resources & forms

All codes listed on the BCBSAZ Health Choice PA grid require prior authorization. Visit the Health Choice page for the PA medical request form and more information on authorization requirements.

All grid codes require prior authorization from BCBSAZ Health Choice.
PA medical request form and details: https://www.azblue.com/health-choice-az

Billing Rule

Specialty medication administration & billing instructions

Specialty medications requiring prior authorization may be administered in contracted provider offices or other outpatient settings; provider‑administered medications must be billed as medical claims and the PA form should indicate 'Buy and Bill' or CVS Caremark Specialty Pharmacy as appropriate.

Specialty meds may be administered in contracted offices or outpatient facilities if PA obtained.
Provider-administered medications must be billed as a medical claim.
Indicate 'Buy and Bill' or CVS Caremark Specialty Pharmacy on the PA request form.

Prior Authorization

Synagis PA exception & submission instructions

Synagis (palivizumab) does not require prior authorization for members under two years of age. For other Synagis requests, submit a complete Medical PA request form with supporting documentation by fax to 1-877-422-8120; providers may use CVS Caremark Specialty Pharmacy or 'Buy and Bill'.

Synagis (J0589): No PA required for members < 2 years old.
Submit Medical PA request form with supporting documentation to fax: 1-877-422-8120.
Options: CVS Caremark Specialty Pharmacy or 'Buy and Bill'.

Note

Prior Authorization Grid — partial code list (drugs/products)

The PA grid includes a partial listing of HCPCS/CPT codes and drug/product names (examples include J0589, J3490, G0248, 90380, 90381) that require prior authorization per the grid effective 4/10/25.

Partial drug/product code list present in grid (e.g., J0589, J3490, G0248, 90380, 90381).
Grid effective date: 4/10/25 (revised 3/10/25).

Note

Prior Authorization Grid — reference & effective date

Reference the BCBSAZ Health Choice Prior Authorization Grid (effective 4/10/25; revised 3/10/25) for the complete list of codes and authorization rules.

PA Grid effective 4/10/25; revised 3/10/25.
Use the grid as the authoritative reference for PA code requirements.

Where to confirmSee the PA grid entries and provider manual for ASH-administered chiropractic service details.

inv-72: Prior authorization is a required approval for the listed services and DME before the service is provided; PA is explicitly required for all non‑participating providers and hospitals.

PA is required before servicePrior authorization is a required approval for the listed services and DME before the service is provided; PA is explicitly required for all non‑participating providers and hospitals.

ScopeApplies to numerous CPT/HCPCS/L codes listed on the PA grid; see grid for specific codes.

Provider responsibilityObtain PA prior to service; out‑of‑network providers/facilities must always obtain PA.

inv-73: A single DME item with allowed charges over $500 and 'By Report' codes triggers the requirement for prior authorization.

Trigger for PAA single DME item with ALLOWED charges over $500 and 'By Report' codes triggers the requirement for prior authorization.

Applies toDurable Medical Equipment (DME) & Diabetic Supplies listed on the PA grid.

Action for providersSubmit PA for single-item DME claims exceeding the $500 allowed-charge threshold.

inv-74: PA required — Prior Authorization (PA) required

PA requiredPrior Authorization (PA) required for the services and codes listed on the grid.

Non-par providers/hospitalsPA is required for all non‑participating providers and hospitals as stated in multiple grid sections.

ExamplesIncludes advanced imaging, cardiac imaging, bariatric surgery, prosthetics/orthotics, wound therapy and many CPT/HCPCS codes.

inv-75: Inpatient notification — Facilities must fax inpatient notifications to the HCS fax number provided.

Inpatient notification requirementAll Acute Hospitals (including Maternity & Delivery), Skilled Nursing Facilities (SNF), Rehabilitation, and LTAC facilities must fax inpatient notifications to HCS.

Fax numberFax inpatient notifications to 480-760-4732.

When to notifyNotify HCS of admissions (on admission) as specified in the PA grid provisions.

inv-76: Fax inpatient notifications to 480-760-4732; all facilities must notify HCS of admissions

Inpatient notification faxFax inpatient notifications to 480-760-4732; all facilities must notify HCS of admissions.

Applicable facilitiesAll Acute Hospital (including Maternity & Delivery), SNF, Rehabilitation, LTAC.

ReferenceSee inpatient notification entries on the PA grid for submission details.

inv-77: PA — Prior Authorization (PA) required

PAPrior Authorization (PA) — authorization must be obtained prior to service for listed codes and non‑participating providers.

ValidityAuthorizations are valid for 90 days from date issued.

Submission instructionRefer to the PA medical request form and provider manual Chapter 6 for details and fax submission info.

inv-78: Neurologic Stimulation Devices — Neurologic Stimulation Devices referenced as a specialty/category requiring PA

Category subjectNeurologic Stimulation Devices are referenced as a specialty/category requiring prior authorization.

Example mappingDocument maps 81163 to 61850 for Neurologic Stimulation Devices (see grid entries).

PA statusPA required for Neurologic Stimulation Devices as indicated in multiple grid fragments.

inv-79: Prior Authorization (PA) requirement — PA Required for all non-participating providers and hospitals

PA requirement summaryPrior authorization is required for listed services and codes; PA is explicitly required for all non‑participating providers and hospitals.

Provider actionObtain PA before rendering services listed on the grid; follow eviCore process for imaging where applicable.

Where to find formsPA request forms and additional instructions are available at https://www.azblue.com/health-choice-az.

inv-80: Place of Service mapping — Place of Service 22 = Outpatient Hospital; Place of Service 24 = Ambulatory Surgery Center

Place of Service mappingPlace of Service 22 = Outpatient Hospital; Place of Service 24 = Ambulatory Surgery Center (as used in grid entries).

ApplicabilityMany L-code and procedure entries specify POS 22 or 24 for prior authorization requirements.

Provider noteVerify POS when submitting PA requests for outpatient hospital or ASC services.

inv-81: Prior Authorization / Place of Service — Prior authorization required for all non-participating providers and hospitals; Outpatient Hospital (Place of Service 22) and Ambulatory ...

PA & POS notePrior authorization required for listed codes; many entries specify Outpatient Hospital (POS 22) and Ambulatory Surgery Center (POS 24) applicability.

ExamplesL-codes and neurology/EEG testing entries reference POS 22 & 24 in the grid.

ActionInclude Place of Service on PA submissions where specified.

inv-82: Prior Authorization is required for services listed; required for all non-participating providers and hospitals

PA required for listed servicesPrior Authorization is required for the services and CPT/HCPCS/L codes listed on the grid; applies to non‑participating providers and hospitals.

Imaging via eviCorePrior authorizations for MRI, MRA, CT and PET must be obtained through eviCore (see eviCore instructions in grid).

Provider instructionFollow grid entries and eviCore process for imaging; obtain PA before service is rendered.

inv-83: Third-party utilization management vendor responsible for prior authorization of MRI, MRA, CT and PET services.

Third-party UM vendoreviCore is the third‑party utilization management vendor responsible for prior authorization of MRI, MRA, CT and PET services.

How to obtainPrior authorizations for these imaging services must be obtained through eviCore (phone/web options referenced in the grid).

ReferenceSee 'IMAGING / PROCEDURES' section for eviCore routing instructions.

inv-84: Services listed in these chunks must obtain PA before being performed; applies to listed CPT codes and non-participating providers/hospitals.

PA before servicesServices listed in the PA grid must obtain prior authorization before being performed.

Codes and providersApplies to the CPT/HCPCS/L codes listed and to all non‑participating providers and hospitals shown in the grid entries.

Where to submitRefer to the PA medical request form via the Health Choice web page for submission details and supporting documentation requirements.

inv-85: Prior authorization — a requirement that certain procedures, services or medications have approval from BCBSAZ Health Choice before they are provided/billed

Prior authorization definitionPrior authorization is a requirement that certain procedures, services or medications have approval from BCBSAZ Health Choice before they are provided or billed.

Provider implicationProviders must ensure PA is obtained when required and that the member is eligible at time of service.

Validity periodAuthorizations are valid for 90 days from the date issued.

inv-86: Buy and Bill — provider procurement and billing method for specialty medications where the provider purchases medication and bills the pa...

Buy and Bill definition'Buy and Bill' — provider procurement and billing method where the provider purchases specialty medication and bills the payer as a medical claim.

AlternativesCVS Caremark Specialty Pharmacy is an option; indicate 'Buy and Bill' or CVS Caremark on the PA request form.

Billing noteProvider‑administered specialty medications must be billed as medical claims when PA is required and obtained.

inv-87: BCBSAZ Health Choice Prior Authorization Grid (effective 4/10/25; revised 3/10/25)

PA grid referenceBCBSAZ Health Choice Prior Authorization Grid (effective 4/10/25; revised 3/10/25).

PurposeLists codes and services that require prior authorization and provides submission resources.

Where to accessSee https://www.azblue.com/health-choice-az for the PA medical request form and additional info.

inv-88: Prior Authorization Grid — BCBSAZ Health Choice prior authorization grid

Prior Authorization GridThe BCBSAZ Health Choice prior authorization grid listing services, CPT/HCPCS/L codes, and PA requirements.

Effective dateEffective 4/10/25 (revised 3/10/25) as shown in the document header and grid sections.

UsageUse the grid to determine which services require PA and follow listed provider instructions for submission.