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Medicaid Pre-Auth

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DISCLAIMER:

All attempts are made to provide the most current information on the Pre-Auth Needed Tool. However, this does NOT guarantee payment. Payment of claims is dependent on eligibility, covered benefits, provider contracts, correct coding and billing practices. For specific details, please refer to the provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response. All new, re-sequenced and unlisted codes (miscellaneous codes) require prior authorization, regardless of place of service.

For Home Health, please request prior authorizations through Tango Care (formerly PHCN)

 

Preventative Vision Services need to be verified by Envolve Vision. 

 

Dental Services need to be verified by Envolve Dental.

 

Complex imaging, MRA, MRI, PET, and CT scans need to be verified by Evolent.

 

For Oncology/supportive drugs, please request prior authorizations through Evolent /New Century Health (NCH)

 

Musculoskeletal Services need to be verified by Turning Point.

 

Chiropractic services are handled by American Specialty Health Network (ASH).

 

Transportation services are handled by MTM (formerly MTBA).

 

Requests for Reinsurance Drugs must be submitted through the pharmacy benefit with Cover My Meds or by fax. Visit AHCCCS website for Information on AHCCCS Reinsurance including drugs and manuals.

 

Requests for elective clinical trials must be submitted as
expedited requests and with the completed
MEDICAID ATTESTATION FORM ON THE APPROPRIATENESS
OF THE QUALIFIED CLINICAL TRIAL
found in the AHCCC Medical Policy Manual Section 320B.
 

Non-participating providers must submit Prior Authorization for all services except those performed in the Emergency Department and Urgent Care.

For non-participating providers, Join Our Network.

Are Services being performed in the Emergency Department or Urgent Care Center or Family Planning services billed with a Contraceptive Management diagnosis?

Types of Services YES NO
Is the member being admitted to an inpatient facility?
Are anesthesia services being rendered for dental procedures?

To submit a prior authorization Login Here.

Prior Authorization (PA) Changes

Arizona Complete Health-Complete Care Plan utilizees Prior Authorization criteria that has been reviewed and approved by AHCCCS. To review prior aurhorization requirements for a drug that requires PA or is not on the Care1st formulary visit the AHCCCS Pharmacy page.

Additional PA criteria may apply. For drug specific PA Criteria not inclided on the AHCCCS Fee-For-Service PDF (link above), please call provider services at 888-788-4408 to request a copy of the PA criteria.

For oncology/supportive drugs, please request through Evolent.

Please note, failure to obtain authorization may result in administrative claim denials.
 

For Home Health, please request prior authorizations through Tango Care (formerly PHCN)