Prior Authorizations for Experimental Services and Clinical Trials

Date: 10/25/22

In accordance with recent AHCCCS updates to AMPM 320 B Member Participation in Experimental Services and Clinical Trials, effective October 1, 2022, Arizona Complete Health-Complete Care Plan (AzCH-CCP) requires prior authorization for codes S9988, S9990 and S9991.

When requesting prior authorization for experimental services and clinical trials please:

·         Mark your request as expedited

·         Complete and attach the “Medicaid Attestation Form on the Appropriateness of the Qualified Clinical Trial”

·         The Attestation is located on the AHCCCS website in the AHCCCCS Medical Policy Manual > Chapter 300 Medical Policy for Covered Services > 320, Services with Special Circumstances > 320B-Attachment A, Medical Attestation Form on the Appropriateness of the Qualified Clinical Trial: https://www.azahcccs.gov/shared/MedicalPolicyManual/.

It is critical we receive the completed Medicaid Attestation Form with your request in order to process it!

If you have any questions, please contact your AzCH Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us at AzCHProviderEngagement@azcompletehealth.com.