CurrentBlue Cross Blue Shield - ArizonaPolicy N/A

Medical Policies and Prior Authorization

Governs how Blue Cross Blue Shield of Arizona (BCBSAZ) medical policies, clinical criteria reviews, and prior authorization processes are applied for commercial plans and related provider requirements.

Policy Summary

PayerBlue Cross Blue Shield - Arizona

PolicyMedical Policies and Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRequest prior authorization before scheduled inpatient admissions and specified outpatient procedures to avoid claim denials or penalties.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

annualclinical criteria review frequency

365 daysauthorization validity for diabetic supplies

90 daysstandard authorization validity period

$500penalty for failure to obtain required PA (typical)

7 daystimeframe to request peer-to-peer after denial

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Coverage and Authorization Criteria

Administrative and prior authorization criteria

Covered when ALL of the administrative prerequisites are met

PA timing and scope: Prior authorization must be obtained before the service is rendered for scheduled inpatient admissions and certain outpatient procedures, services, items, and medications as defined by plan-specific prior authorization grids.before service

Refer to the ACA StandardHealth with Health Choice prior authorization grid and the Secure Provider Portal for the current list of services requiring prior approval.

Clinical necessity review: Authorization decisions are based on member eligibility, benefit coverage (including contract limitations, exclusions, waiting periods, waivers, and benefit maximums), provider network status and site-of-service requirements, and medical necessity per applicable evidence-based clinical standards and criteria.meets clinical criteria

Clinical criteria sources include external vendors and national guidelines (e.g., eviCore, InterQual, ASH, NCCN) and BCBS proprietary policies.

Inpatient notification: All scheduled and unscheduled inpatient admissions and continued stays require notification and/or prior authorization; facilities must notify and obtain authorization prior to or at the time of admission.notification/PA obtained

For emergent admissions, notify the plan within one calendar day of presentation and follow plan-specific timeframes.

Prior Authorization Determination Outcomes

Prior authorization determinations are processed into one of three outcomes based on clinical documentation:

Approved: Information received met all clinical documentation requirements to determine medical necessity to authorize the requested services.

The requesting provider office is responsible for informing the member and providing the authorization to the specialist or facility.

Denied: Information received did not meet requirements and authorization is not granted; the requesting provider and member will receive a denial notification letter.

Members may pursue appeal or reconsideration if prior authorization is not approved; notification timeframes apply (see pre-service denials timelines).

Modified: Information received met medical necessity requirements but a partial authorization is granted; requested services may be reduced in amount, duration, or scope.

Provider receives notification of the partial authorization and any limitations on amount, duration, or scope.

Hospital Services Authorization Criteria

Hospital admissions and concurrent review requirements:

Inpatient admission notification: All non-emergency hospital admissions (including Acute, Observation, Rehabilitation, Skilled Nursing, and Hospice) require prior authorization; facilities must notify and obtain authorization prior to or at the time of all admissions.

For emergency admissions, notify the plan within one calendar day of presentation by fax to the Inpatient Notification Fax Number; failure to provide requested information within 24 hours for initial review or within 48 hours for concurrent reviews may result in administrative denial for lack of medical information.

Psychiatric Inpatient Authorization

Psychiatric inpatient authorization rules:

Psychiatric initial and continued stay: Submit the Health Choice Prior Authorization and Continued Stay Request Form for Psychiatric Hospitals and Sub-Acute Facilities with supporting documentation within one business day of admission; admission reviews are completed by Medical Management and authorizations are based on medical necessity criteria.

Facility must fax requests to the listed number; continued stay reviews occur prior to the end of the current authorization, updated clinical information must be submitted by noon on the last authorized day, and discharge notifications/summaries must be submitted within 1 business day of discharge.

Service coverage and administrative requirements

Coverage and administrative requirements for the listed services

Ophthalmology/Optometry: Eye and optometric services are covered when provided by qualified professionals, based on member age and eligibility; contracted providers offer cataract surgery, keratoconus treatment, and pediatric vision services.

Refer to Member Eligibility and Benefits Guide for details about covered eye and vision services and age-based limits.

DME: Requests for durable medical equipment must be sent to the plan for prior authorization; medical records documenting medical necessity and a current, signed doctor's order or prescription must be provided.

The plan will coordinate with the requesting provider and uses contracted DME suppliers.

Orthotics/Prosthetics: Requests for customized orthotics and prosthetics must be submitted by the requesting physician/provider on a prior authorization form with supporting clinical documentation.

Contracted orthotics and prosthetics providers are used in the geographical areas served.

Peer-to-peer conversations are not available for matters that fall outside plan coverage. Examples include benefit plan exclusions and non-covered benefits such as dosing outside FDA-recommended doses, out-of-network services, and items or services considered experimental or investigational. Additionally, retrospective reviews where prior authorization was required but not obtained before services were rendered are not eligible for a peer-to-peer discussion.

Neither peer-to-peer conversations nor prior authorization processes apply when the issue is a benefit plan exclusion or non-covered benefit (for example, dosing outside FDA recommendations or excluded out-of-network services), or when the matter involves denied claims, active or upheld member appeals, credentialing decisions, or other administrative determinations. Requests received more than seven calendar days after the prior authorization denial letter are also excluded from peer-to-peer review.

Emergency services are not subject to prior authorization at the time care is rendered. A retrospective review may be performed after the emergency to determine whether the service met admission authorization criteria. If the review finds the emergency service did not meet those criteria, payment for the service may be denied. Appropriateness is judged by whether a prudent layperson in similar circumstances would have sought such services.

Provider Requirements and Actions

Denial Risk

Prior authorization required before service — Consequences of not obtaining prior authorization

Prior authorization is required for all scheduled inpatient admissions and certain outpatient procedures, services, items, and medications. Prior authorization must be requested before the service is rendered. Failure to obtain a required prior authorization may result in claim denials, financial penalties to the servicing provider (commonly a $500 assessment for most commercial plans), and potential member financial responsibility when applicable (for example, when the rendering provider is out-of-network on certain PPO plans). To avoid penalties and denials, obtain and document the authorization number prior to providing services and include the identifier on the claim submission.

Penalties: BCBSAZ may assess a $500 penalty to the servicing network provider for failure to obtain required prior authorization; facility-level penalties apply for facility-related prior authorization requirements. Providers in-network may not bill the member for this penalty amount except as specified for some PPO/out-of-network situations.
Authorization validity: Authorizations are generally valid for 90 days (diabetic supplies valid for 365 days; some J-codes may be approved for longer).
Notification: The authorization number or denial should be documented in the member's medical record and provided to Specialist/Facility/Vendor prior to appointment.

Documentation Required

Required information for PA requests

Providers must supply complete patient and provider details and relevant clinical and service information when submitting a prior authorization or notification to ensure timely processing.

Member/subscriber name, date of birth, and ID number
Provider name(s), NPI, specialty, and contact information
Date, type, and place of service
Applicable procedure(s) and procedure code(s) and applicable diagnosis(es) and diagnosis code(s)
Other relevant clinical information specific to the request (history, prior treatments, imaging/lab reports, indications, alternatives discussed)

Prior Authorization

Use of external criteria and plan-specific PA grids

BCBSAZ and ACA StandardHealth with Health Choice use external vendor and nationally recognized clinical criteria and plan-specific prior authorization grids to determine medical necessity and authorization decisions. Providers should reference the plan-specific PA grid and applicable external criteria when preparing requests.

External criteria/vendors include eviCore, Change Healthcare InterQual®, American Specialty Health (ASH), NCCN®, BCBS Association, and proprietary BCBSAZ criteria.
Refer to the ACA StandardHealth with Health Choice prior authorization grid (posted online) for the most up-to-date list of services requiring prior authorization and plan-specific rules.
Some services administered by contracted vendors may follow the vendor's evidence-based criteria.

Prior Authorization

Non-formulary / out-of-network requirements

Requests for out-of-network services, non-formulary medications, or non-preferred products require specific medical necessity documentation explaining why an in-network or preferred alternative is not appropriate. Prior authorization is required for coverage of services at out-of-network providers/facilities.

For OON providers/facilities and NF or non-preferred medication/product requests, include explicit justification and supporting clinical documentation describing medical necessity for the out-of-network or non-formulary request.
A PA is required for any service to be covered at out-of-network providers/facilities.
Pharmacy prior authorizations and any step therapy rules are referenced in Chapter 17 Pharmacy and Drug Formulary.

Definitions and Evidence Sources

Evidence sources / Evidence Street — Evidence sources include peer-reviewed literature, expert specialty reviews, and professional organization statements; Evidence Street® i...

Primary evidence sourcesHigh-grade peer-reviewed literature, expert specialty reviews, and professional medical organization position statements.

Evidence Street®A proprietary Blue Cross Blue Shield Association web platform used for transparent healthcare evidence reviews and submission of peer-reviewed evidence.

Credible criteria requirementsTechnologies must have regulatory approval, demonstrable effect on health outcomes, improve net patient outcome, and be at least as beneficial as established alternatives.

Ophthalmology/Optometry services — eye and optometric services provided by qualified professionals, based on member age and eligibility

Covered servicesEye and optometric services provided by qualified professionals based on member age and eligibility.

Contracted providersContracted ophthalmology and optometry providers deliver cataract surgery, keratoconus treatment, and pediatric vision services.

Reference for detailsSee Chapter 2: Member Eligibility and Member Services, the Benefits Guide for specifics about covered eye and vision services.

Durable Medical Equipment (DME) — equipment provided by contracted DME providers requiring prior authorization and medical necessity documentation

DefinitionDurable Medical Equipment (DME) provided by contracted DME providers requiring prior authorization and medical necessity documentation.

Prior authorization coordinationRequests for DME must be sent directly to the plan, which will coordinate with the requesting provider to obtain any necessary prior authorization.

Required documentationMedical records documenting medical necessity plus a current, signed doctor's order/prescription must be provided.

Customized orthotics/prosthetics — orthotic or prosthetic devices that require provider-submitted prior authorization with clinical support

DefinitionCustomized orthotics/prosthetics are orthotic or prosthetic devices that require provider-submitted prior authorization with supporting clinical documentation.

Submission requirementRequests for customized orthotics/prosthetics must be sent to the plan by the requesting physician/provider on a prior authorization form.

Provider networkThe plan has contracted orthotics and prosthetic providers in the geographic areas it serves.

OpenPayer

Medical Policies and Prior Authorization

Coverage and Authorization Criteria

Provider Requirements and Actions

Coding and POLT References

Background and Rationale

Definitions and Evidence Sources