Use only Department‑approved prior authorization forms

Providers must exclusively use the Department‑approved uniform prior authorization request forms beginning January 1, 2023; health care services plans and their utilization review agents shall only accept and process those approved forms. Prior authorization requests submitted on other forms on or after January 1, 2023 are invalid. Plans may make nonsubstantive formatting changes provided they do not substantively alter content or layout.

• Mandatory use date: January 1, 2023
• Plans/UR agents must accept and process only the Department‑approved forms
• Nonsubstantive insurer formatting changes permitted if consistent with attached versions

Maintain emergency after‑hours prior authorization procedures

Plans and their utilization review agents are required to implement emergency after‑hours procedures to request a prior authorization so providers can obtain authorizations outside regular business hours.

• After‑hours procedures must allow requests for all health care services, including prescriptions

Publicly list all prior authorization requirements and required documentation

Plans must provide a public listing (via website or provider portal) of all services, drugs, and devices that require prior authorization and the documentation necessary to make a request complete.

• Listing must be accessible through an electronic software system or provider portal

Non‑electronic submissions allowed only for documented hardship or limited connectivity

Plans may accept non‑electronic prior authorization submissions only under a contractual arrangement when the provider demonstrates financial hardship or limited/unavailable connectivity where the provider is located, per A.R.S. § 20‑3403(C).

• Otherwise, plans and UR agents must accept and respond to requests via secure electronic transmission

Use prescribed request types on the form and support expedited review certification

The standardized form includes selectable request types—Initial Request, Continuation/Renewal Request, Prior Authorization, Step Therapy/Formulary Exception, Medical Device, Quantity Exception, DME, Specialty Drug, and Other—and includes an option for prescriber certification to request expedited/urgent review.

• Prescriber may request expedited/urgent review by checking the expedited box and signing the form

Provide service/procedure codes, diagnosis, setting, and therapy details in Section VI

Section VI of the form requests the planned service or procedure with CPT, CDT, or HCPCS code and supporting diagnosis with ICD code, and captures setting (inpatient/outpatient/office/etc.), therapy session counts, duration, frequency, and related attachments (orders, nursing assessment) as applicable.

• Include CPT, CDT, or HCPCS code and ICD diagnosis code(s)
• Specify setting (Inpatient, Outpatient, Provider Office, Observation, Home, Day Surgery, Other)
• Provide therapy details: number of sessions, duration, frequency; attach orders/assessments when required

Complete drug, HCPCS/NDC, and compound ingredient details on the form

Prescription drug fields must include requested drug name, strength, route, quantity, days' supply, expected therapy duration, indication whether new or continuation of therapy, and for provider‑administered drugs the HCPCS code and NDC. The form also includes an expedited/urgent review checkbox with prescriber certification and signature, and fields for drug allergies and relevant laboratory values.

• Requested Drug Name, Strength, Route, Quantity, Days' Supply, Expected Therapy Duration
• Indicate New therapy or Continuation of therapy (with approximate start date)
• Provider‑administered drugs: HCPCS Code and NDC # and Dose Per Administration
• Compound drugs: identify all ingredients in Section VII
• Include drug allergies and relevant laboratory values (attach or list)