Prior Authorizations
Prior Authorization means your doctor has requested permission for you to get a special service, medication or referral. We must approve these requests before the delivery of services. If you or your provider would like a referral to a service that is not a covered benefit, please call Member Services at 1-888-788-4408, TTY/TDD 711 so we can discuss other options available to you.
Some medical and behavioral health services may need Prior Authorization. If they do, your provider will arrange for authorization for these services. We must review these authorization requests before you can get the service.
Below is a list of services that require prior authorization from Arizona Complete Health-Complete Care Plan before your healthcare provider can proceed with treatment.
SERVICES THAT REQUIRE A PRIOR AUTHORIZATION | PRIOR AUTHORIZATION REQUIRED FOR SOME OR ALL OF THE SERVICES? |
|---|---|
Behavioral Health Inpatient Facility | Yes |
Behavioral Health Residential Facility | Some services require prior authorization |
Home Care Training to Home Care Clients (HCTC) | Yes |
Psychological and Neuropsychological Testing | Yes |
Electroconvulsive Therapy (ECT) | Yes |
Non‑emergency out of network services/treatments | Yes |
Some medications, check the list of approved medications (formulary) | Some services require prior authorization |
MRI, MRA, PET scans | Yes |
Special lab work, genetics | Some services require prior authorization |
Surgeries, pre-scheduled | Some services require prior authorization |
Dialysis | Some services require prior authorization |
Some Outpatient procedures and surgeries | Some services require prior authorization |
Transplant | Some services require prior authorization |
Bio pharmacy (Buy and Bill) | Some services require prior authorization |
Criteria that decisions are based on are available upon request.
All such services determined by AHCCCS to be medically necessary shall constitute an Arizona Complete Health-Complete Care Plan Covered Service. See the Arizona Complete Health-Complete Care Plan Member Handbook for more information on coverage out-of-network and out of the Arizona Complete Health-Complete Care Plan service area.
Do I need a referral to see a specialist?
No, you do not need a referral from your PCP to see a specialist. You do not need a referral for routine vision care, chiropractic services, or mental health/counseling services.