Prior Authorization
Please note, failure to obtain authorization may result in administrative claim denials. Arizona Complete Health providers are contractually prohibited from holding any member financially liable for any service administratively denied by Arizona Complete Health for the failure of the provider to obtain timely authorization.
Check to see if a pre-authorization is necessary by using our online tool.
Expand the links below to find out more information.
As the Medical Home, PCPs should coordinate all healthcare services for Arizona Complete Health members. Paper referrals are not required to direct a member to a specialist within our participating network of providers.
All out of network services (excluding ER and family planning) require prior authorization. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient’s medical record.
Some services require prior authorization from Arizona Complete Health in order for reimbursement to be issued to the provider. See our Prior Authorization List, which will be posted soon, or use our Prior Authorization Prescreen tool.
Standard prior authorization requests should be submitted for medical necessity review as soon as the need for service is identified.
Authorization requests may be submitted via web portal, fax or phone and must include all necessary clinical information pertinent to the requested treatment/services. Urgently identified services/treatment that need to occur the same day as the member’s need is identified should be called in immediately.
Prior Authorization Request Turnaround Times:
- Standard Request - 14 calendar days*
- Expedited (Urgent) Request – 72 hours* the provider must sign the request to certify the request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 72 hours to avoid complications and unnecessary suffering or severe pain.
* A possible extension of up to 14 calendar days can be requested by the member or provider or, if AzCH-CCP justifies a need for additional information and the delay is in the member’s best interest.
Authorization determinations may be communicated to the provider by fax, phone, secure email, or secure web portal.
Please note that an authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with prior authorization as per Plan policy and procedures.
Arizona Complete Health’s Medical Management department hours of operation are 8 a.m. to 5 p.m. Monday through Friday (excluding holidays). After normal business hours, the Envolve nurse line staff are available to answer questions and intake requests for prior authorization. Emergent and post-stabilization services do not require prior authorization.
Facility discharge planning should be initiated within the first 24 hours of admission to provide continuity of care for the member, AzCH-CCP Care Managers are available for assistance by calling 1-888-788-4408. AzCH-CCP Concurrent Review nurses will review the member’s admission for medical necessity within 1 business day of notification of admission and will continue to follow the member’s care regularly throughout their confinement, assessing for medical necessity, discharge planning and quality of care.
We will process most routine authorizations within five business days. If we need additional clinical information or the case needs to be reviewed by the Medical Director it may take up to 14 calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email, or secure web portal.