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New Prior Authorization Forms Required for Ambetter *2nd Reminder*

Date: 11/18/22

Effective 1/1/2023, as required by Arizona Revised Statutes (A.R.S.) § 20-3406 and outlined by the Arizona Department of Insurance and Financial Institutions (DIFI)  Regulatory Bulletin 2022-01(INS), AZ Marketplace and commercial insurers are required to implement two new uniform prior authorization (PA) forms approved by the DIFI.

A.R.S. § 20-3406 requires all PA requests for Marketplace and commercial members to be submitted on one of the new forms.  The statute not only requires providers to use the new forms exclusively, it also prohibits health plans from accepting any other form if submitted by fax. PA requests that are submitted on forms other than the approved forms on or after 1/1/2023 will be considered invalid.

We will begin to accept the new forms as of 12/1/2022, a month prior to their required use. Until 1/1/2023 the existing forms may continue to be used as well.

There are two new forms:

1.      Arizona Standard Prior Authorization Request Form for Health Care Services

2.      Arizona Standardized Prior Authorization Request for Medication, DME and Medical Device

We will post both fillable PDF forms on our website: > For Providers > Pre-Auth Check

Health plans are not allowed to alter either form other than to add our logo, our contact information, and other minimal edits.

This is a big change for all of us! For the first time health plans will be required to reject requests simply due to the form received.  As a result, please consider submitting requests for healthcare services including medical drugs/J codes/”buy and  bill”/medical device/DME/O&P via our secure provider portal and pharmacy requests via CoverMyMeds There are no changes to the portal submission processes, and you avoid a potential rejection if you use an old form!  

If you have questions regarding the information contained in this update please  contact your Provider Engagement Specialist and if you need your assigned Provider Engagement Specialist contact information, email us at