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.

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.

• 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.

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 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 — 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.

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.

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.

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.

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.

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).

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.

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.

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

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.

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'.

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).

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.