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Reinstating Prior Authorization and Concurrent Review

Date: 04/01/21

The “AHCCCS Prior Authorization (PA) and Concurrent Review (CR) Standards during COVID-19 Emergency for Health Plans” Memo was updated in early April.  The memo is embedded in question 1 of the Clinical Delivery section of the AHCCCS COVID-19 FAQs:

https://azahcccs.gov/AHCCCS/Downloads/COVID19/AHCCCS_PAandCR_StandardsCOVID19_20201212.pdf

Arizona Complete Health Complete Care Plan will follow AHCCCS’ recent updates to the guidelines outlined in the memo.  These updates are outlined below.  All other information contained in the memo remains the same.

Section III - Pharmacy Services (page 2-4)

  • Section III.A Refill-too-soon edits and 90 day fills - Reinstated effective 6/1/21
  • Section III.B Addressing Drug Shortages - Ceasing approval of non-preferred medication effective 6/1/21

Section IV Physical Health Services, B. Inpatient Services (page 4-5)

  • Continue removal of any prior authorization and concurrent review requirements for observation units and acute inpatient hospitalization for:
    • Admissions where COVID-19 infection is suspected
    • Admissions where COVID-19 infection is confirmed
    • Admissions related to COVID-19, even where the person receiving the service is not themselves suspected or confirmed to be infected; this may include admissions that are necessary to create treatment capacity, prevent transmission of COVID-19 infection, or admissions that become necessary because of another individual being infected by COVID-19. Services must be medically necessary, cost-effective, and federally and state reimbursable.
  • Re-instate prior authorization and concurrent review requirements for observation units and acute inpatient hospitalization for admissions not listed above effective 4/15/21
  • Continue removal of prior authorization requirements and maintain concurrent review for the following levels of care:
    • Assisted Living Facilities/Centers, and
    • Skilled Nursing Facilities (SNFs)
  • Re-institute prior authorization and concurrent review for Inpatient Rehabilitation Facilities and Long Term Acute Care Hospitals for admissions other than those listed above under 1 and 3 effective 4/15/21.
  • Continue to reimburse AHCCCS registered in-network and out-of-network facilities for inpatient and post-acute services during the COVID-10 emergency.
  • Continue ongoing care management activities to ensure members stable for discharge to a lower level of care have safe and effective transitions of care. These care management activities may be conducted telephonically or via telehealth. Hospital notification to health plans of admission will allow health plans to assist in discharge planning

Section IV Physical Health Services, C. Outpatient Services (page 5)

There are no changes to this section. We encourage you access our Medicaid Pre Auth Check Tool on our website https://www.azcompletehealth.com/providers/preauth-check.html for current outpatient prior authorization requirements.