Prior Authorization & Clinical Guidelines

Last Updated: June 12, 2024 at 6:32 pm

At BCBSAZ Health Choice Pathway HMO D-SNP, our goal is to work closely with providers to streamline and expedite prior authorization requests for our members. Many of the items on our abbreviated prior authorization list ask for notification only. Our centralized prior authorization center is designed to streamline processes resulting in timely expedited approval of prior authorization requests.

Referrals and Prior Authorizations

Referrals

A referral is a written order from your primary care provider (PCP). In some situations, our plan or your PCP must give you a referral for you to get certain medical services from another provider in our plan.

You can get the services listed below without getting a referral from your PCP.

• Emergency care or urgently needed services
• Flu shots, COVID-19 vaccinations, Hepatitis B vaccinations, and pneumonia vaccinations
• Routine women’s health care includes breast exams, screening mammograms (x-rays of the breast), Pap tests, and pelvic exams as long as you get them from an in-network provider.
• In-network Specialist provider office visits do not require a referral, except for pain management services.

You can also get other kinds of care without a referral from your PCP (see Section 2.2 of Chapter 3 in your Evidence of Coverage).

Prior Authorizations

Some medical tests or services require prior authorization before they are scheduled.  Your provider requests prior authorization on your behalf.  A prior authorization, commonly called a ‘PA’, is not a promise BCBSAZ Health Choice Pathway will cover the cost of the service.

A PA request is a form your provider fills out and sends to BCBSAZ Health Choice Pathway. Our prior authorization department will review the request and make a decision. A decision for a standard request is made within 14 calendar days and a decision for an expedited request is made within 3 calendar days. You and your provider will be notified if the service is approved or denied.

If you have a question about referrals and prior authorizations, Member Services can help you. Call us at 1-800-656-8991 (TTY 711). Our Member Services department is open 8 a.m. to 8 p.m., 7 days a week. You can also contact us by e-mail at HCHComments@azblue.com.

Prior Authorization Guidelines

Requests for services that require prior authorization can be submitted on the BCBSAZ Health Choice Pathway Prior Authorization form directly through the secure provider portal or via fax to the Authorizations department. All requests must include complete diagnosis and procedure codes, and the accompanying medical documentation (as needed).

In order to expedite prior authorization and provide quality services to our members, a contracted or preferred provider is recommended for all health care services for BCBSAZ Health Choice Pathway members. Please note that all non-contracted providers must obtain authorization for any service. All out of state provider must have or be willing to obtain a valid and current AHCCCS ID number. AHCCCS-covered out of state care must be of an urgent or emergent nature.

Submitting a Prior Authorization

• BCBSAZ Heath Choice Pathway Medical PA Phone: 1-800-656-8991
• BCBSAZ Heath Choice Pathway Medical PA Fax Line: 1-877-424-5680
• BCBSAZ Health Choice Pharmacy PA Fax Line: 1-877-424-5690
  Click here to access Prior Authorization Forms

Prior Authorization Forms

EviCore

BCBSAZ Health Choice is partnered with EviCore for radiology benefits management of select MR, CT, PET, ultrasound and cardiac imaging studies.

To submit a new request for imaging services and select cardiac testing/procedures, providers may contact EviCore by:

Phone: 1-888-693-3211
Fax: 1-888-693-3210
Email: ClientServices@Evicore.com
Provider Portal: https://www.evicore.com/pages/providerlogin.aspx

Prior Authorization Guidelines

Clinical Guidelines and Recommendations

Centers for Medicare and Medicaid Services – Medicare Coverage Database

BCBSAZ Health Choice Pathway utilizes:

• InterQual
• UpToDate
• National Coverage Determinations (NCD) 
• Local Coverage Determinations (LCD)
• Oncology Clinical Practice Guidelines 
• DrugDex AHFS (subscription required)
• Arizona Controlled Substance Prescription Drug Monitoring Program (login required)

Adult Hypertension Management Guidelines (NHLBI)

• JNC 7 Report on Prevention, Detection, Evaluation and Treatment of High Blood Pressure

Adult Obesity Management Guidelines (NHLBI and NIDDKD)

• Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults

Asthma & COPD Management Guidelines (NHLBI)

• Guidelines for the Diagnosis and Management of Asthma
• COPD Guidelines

Cardiac and CVA Care Management (ACC/AACE)

• NCEP III Guideline

HIV Management Guidelines

• CDC/NIH

Opioid Safety

• CDC Clinical Practice Guidelines for Prescribing Opioids and Recommending Naloxone 
• AZ Provider Resources such as coordinating care and using the Prescription Drug Monitoring Program  

Smoking Cessation Guidelines (NIH)

• Tobacco Cessation