Medical Policies and Prior Authorization
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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.
No material clinical or coverage changes in this revision.
Coverage and Authorization Criteria
Administrative and prior authorization criteria
Covered when ALL of the administrative prerequisites are met
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 criteria sources include external vendors and national guidelines (e.g., eviCore, InterQual, ASH, NCCN) and BCBS proprietary policies.
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:
The requesting provider office is responsible for informing the member and providing the authorization to the specialist or facility.
Members may pursue appeal or reconsideration if prior authorization is not approved; notification timeframes apply (see pre-service denials timelines).
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:
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:
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
Refer to Member Eligibility and Benefits Guide for details about covered eye and vision services and age-based limits.
The plan will coordinate with the requesting provider and uses contracted DME suppliers.
Contracted orthotics and prosthetics providers are used in the geographical areas served.
See Chapter 17 (Pharmacy and Drug Formulary) for pharmacy authorization requirements and step therapy specifics.
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
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.
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)
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.
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.
Coding and POLT References
| No codes listed |
Background and Rationale
BCBSAZ bases clinical policy and utilization management on nationally recognized, evidence-based guidelines and proprietary review tools. Sources include external vendor criteria (for example, eviCore and InterQual), specialty society guidance (such as ASH and NCCN), peer-reviewed literature, expert specialty review, and the Blue Cross Blue Shield Association’s Evidence Street® platform. Clinical criteria are reviewed at least annually and must demonstrate regulatory approval, improvement in patient outcomes, or benefit over alternatives before being applied to coverage decisions.
Definitions and Evidence Sources
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.