Outpatient Authorization Supplemental Forms

Date: 02/14/25

Arizona Complete Health has created Outpatient Authorization Supplemental Forms for each line of business to be utilized when a prior authorization request involves more than four procedure codes. General information about these forms is below, and the forms also are included with this communication.

What is an Outpatient Authorization Supplemental Form? An optional page meant to be used in conjunction with the applicable Outpatient Prior Authorization Request form when a request exceeds more than four procedure codes. The Outpatient Supplemental Form should never be submitted alone.

When to use an Outpatient Authorization Supplemental Form? When requesting prior authorization for more than four procedure codes.

Is the Outpatient Authorization Supplemental Form required to be submitted with all Prior Authorization requests? No, it is an optional page. If your prior authorization request is four procedure codes or less this page is not necessary or required.

Where can I find the Outpatient Authorization Supplemental Page? The Outpatient Authorization Supplemental Forms are located on our website under For Providers > Pre-Auth Check.  

If you have questions, please contact your AzCH Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us.