Prior Authorization Updates Effective December 1 2021
Date: 12/01/21
We are making updates to our prior authorization requirements for Arizona Complete Health-Complete Care Plan (Medicaid) and Ambetter (Marketplace).
Please use the Pre-Auth Check Tool on our website to confirm if a specific code(s) requires prior authorization. When checking Medicaid prior authorization requirements, please select the Medicaid tool. When checking Marketplace prior authorization requirements, please select the Marketplace tool. Prior authorization requirements vary based on the line of business. The Pre-Auth Check tool is located here: https://www.azcompletehealth.com/providers/preauth-check.html.
The tables on pages 2-4 outline the changes to the Pre-AuthCheck tool.
DID YOU KNOW?!
Effective June 14, 2021, a redesign of the authorization request section of our Secure Provider Portal went live for Medicaid and Marketplace lines of business. This redesign includes the integration of InterQual Connect.
The web authorization request redesign and InterQual Connect offer improvements and new capabilities:
- The web authorization request process was simplified. The Service type drop down was replaced by Provider type and has a shorter list of options to choose from.
- You are advised whether or not a service requires authorization or is not covered.
- Following the submission of your request, the tool identifies if one or more service lines were not submitted as part of your request and provides the reason for non-submittal, e.g., an authorization is already on file, the service doesn’t require authorization, etc.
- An assigned Authorization ID on submitted web authorization service lines is provided to you when a request is submitted.
- For a small subset of codes, you also have the ability to access InterQual Connect and complete a medical review.
If you have questions regarding the information contained in this update, please contact our Provider Customer Service Center at (866) 796-0542 or your Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us at AzCHProviderEngagement@azcompletehealth.com.
Procedure Code | Description | Rule |
99439 | CHRONIC CARE MANAGEMENT SERVICES EA ADDL 20 MIN. | No auth required for par providers |
99451 | NTRPROF PHONE/NTRNET/EHR ASSMT AND MGMT 5/> MIN | No auth required for par providers |
99452 | NTRPROF PHONE/NTRNET/EHR REFERRAL SVC 30 MIN | No auth required for par providers |
99453 | REM MNTR PHYSIOL PARAM 1ST SET UP PT EDUCAJ EQP | No auth required for par providers |
99454 | REM MNTR PHYSIOL PARAM 1ST DEV SUPPLY EA 30 D | No auth required for par providers |
95801 | SLP STDY UNATND W/ANALYSIS | No auth required for par providers |
95803 | ACTIGRAPHY TESTING | No auth required for par providers |
42821 | TONSILLECTOMY & ADENOIDECTOMY; AGE 12/OVER | No auth required for par providers |
42825 | REMOVAL OF TONSILS | No auth required for par providers |
42830 | REMOVAL OF ADENOIDS | No auth required for par providers |
42831 | REMOVAL OF ADENOIDS | No auth required for par providers |
42835 | ADENOIDECTOMY SECNDRY; UNDER AGE 12 | No auth required for par providers |
42836 | REMOVAL OF ADENOIDS | No auth required for par providers |
G0398 | HOME SLEEP TEST/TYPE II PORTA | No auth required for par providers |
G0400 | HOME SLEEP TEST/TYPE IV PORTA | No auth required for par providers |
J1650 | INJECTION, ENOXAPARIN SODIUM, 10 MG | No auth required for par providers |
S8990 | PHYSICAL OR MANIPULATIVE THRPY PRFRMD/MNTNC RATHER THAN RESTORATION | No auth required for par providers |
S9131 | PHYSICAL THERAPY | No auth required for par providers |
Procedure Code | Description | Rule |
G0129 | OCCUP THERAP TX PROG/DA-PART HOS | No auth required for par providers |
97010 | APPLIC MODAL 1/> AREAS; HOT/COLD PACKS | No auth required for par providers |
97012 | APPLIC MODAL 1/> AREAS; TRACTION-MECH | No auth required for par providers |
97018 | APPLIC MODAL 1/> AREAS; PARAFFIN BATH | No auth required for par provider |
97022 | APPLIC MODAL 1/> AREAS; WHIRLPOOL | No auth required for par provider |
97024 | APPLIC MODAL 1/> AREAS; DIATHERMY | No auth required for par provider |
97026 | APPLIC MODAL 1/> AREAS; INFRARED | No auth required for par provider |
97028 | APPLIC MODAL 1/> AREAS; ULTRAVIOLET | No auth required for par provider |
97032 | APPLIC MODAL 1/> AREAS; ELEC STIM EA 15 MIN | No auth required for par provider |
97033 | APPLIC MODAL 1/> AREAS; IONTOPHORESIS EA 15 MIN | No auth required for par provider |
97034 | APPLIC MODAL 1/> AREAS; CONTRAST BATHS EA 15 MIN | No auth required for par provider |
97035 | APPLIC MODAL 1/> AREAS; ULTRASOUND EA 15 MIN | No auth required for par provider |
97036 | APPLIC MODAL 1/> AREAS; HUBBARD TANK EA 15 MIN | No auth required for par provider |
97116 | THERAP PROC 1/> AREAS EA 15 MIN; GAIT TRAINING | No auth required for par provider |
97139 | THERAP PROC 1/> AREAS EA 15 MIN; UNLISTED | No auth required for par provider |
97533 | SENSORY INTEGRATION | No auth required for par provider |
97537 | COMMUNITY/WORK REINTEGRATION | No auth required for par provider |
97542 | WHEELCHAIR MGMT/PROPULSION TRAIN-EA 15 MIN | No auth required for par provider |
97545 | WORK HARDENING/CONDITIONING; INIT 2 HR | No auth required for par provider |
97546 | WORK HARDENING/CONDITIONING; EA ADD HR | No auth required for par provider |
97750 | PHYS PERFORMANCE TEST/MEASUR W/REPORT EA 15 MIN | No auth required for par provider |
Medicaid (cont.) | ||
Procedure Code | Description | Rule |
97760 | ORTHOTIC MGMT&TRAINJ 1ST ENC | No auth required for par provider |
97761 | PROSTHETIC TRAINJ 1ST ENC | No auth required for par provider |
97762 | CHECKOUT F/ORTHOTIC/PROSTC USE EST PT EA 15 MIN | No auth required for par provider |
E0467 | HOME VENTILATOR MULTI-FUNCTION RESPIRATORY DEVC | Auth required for all providers |
G0260 | INJ SI JNT; ANES &/TX AGT &ARTHROG | Auth required for all providers |
REV 780 | TELEMEDICINE | Auth required for all providers |
Marketplace | ||
Procedure Code | Description | Rule |
42820 | TONSILLECTOMY & ADENOIDECTOMY; UNDER AGE 12 | No auth required for par providers |
42821 | TONSILLECTOMY & ADENOIDECTOMY; AGE 12/OVER | No auth required for par providers |
42825 | REMOVAL OF TONSILS | No auth required for par providers |
42826 | TONSILLECTOMY PRIM/SECNDRY; AGE 12/OVER | No auth required for par providers |
42830 | REMOVAL OF ADENOIDS | No auth required for par providers |
42831 | REMOVAL OF ADENOIDS | No auth required for par providers |
42835 | ADENOIDECTOMY SECNDRY; UNDER AGE 12 | No auth required for par providers |
42836 | REMOVAL OF ADENOIDS | No auth required for par providers |
95803 | ACTIGRAPHY TESTING | No auth required for par providers |
J1650 | INJECTION, ENOXAPARIN SODIUM, 10 MG | No auth required for par providers |
J1655 | INJECTION, TINZAPARIN SODIUM, 1000 IU | Auth required for all providers |
S9131 | PHYSICAL THERAPY | No auth required for par providers |