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Medical Services Prior Authorization Form - Health Choice Arizona 2025

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The document is a Prior Authorization Form for medical services, requiring providers to complete it with necessary patient and service details, including diagnosis codes and procedure information. It outlines the process for submitting requests to Health Choice Arizona and Health Choice Generations, emphasizing the importance of providing complete medical documentation to avoid service denial. The form also includes sections for approval or denial by medical directors based on medical necessity.

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Click ‘Get Form’ to open the Medical Services Prior Authorization Form in the editor.
Begin by filling in the Member Name, Member ID#, and Date of Birth. Ensure accuracy as this information is crucial for identification.
Next, provide details about the Requesting Provider, including their name, NPI#, and contact information. If there is a different Primary Care Provider (PCP), include that as well.
In the Diagnosis section, enter up to three ICD-9 codes that correspond to the member's condition. This helps in justifying the medical necessity of the requested service.
Select whether you are requesting Standard or Expedited authorization based on urgency. Be mindful that inappropriate expedited requests may be downgraded.
Fill in details about the procedure, including CPT codes and any ancillary services required. Attach additional documentation if necessary.
Review all entered information for completeness before submitting. Incomplete forms may lead to denial of service.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can I request my own prior authorization?

You can submit a request on your own. Find the appropriate prescription drug or medical procedure authorization form for your situation.

Is Steward Health Choice the same as Health Choice Arizona?

Phoenix, Ariziona Health Choice Arizona, a subsidiary of Steward Health Care System, LLC (Steward), today announced that the Arizona Health Care Cost Containment System (AHCCCS) has awarded Steward Health Choice Arizona a full-risk, Medicaid managed care contract to manage physical and behavioral health care for

How to obtain prior authorization?

How To Get Prior Authorization: Step-by-Step Guide Step 1: Check client eligibility. Step 2: Determine if a code or service requires Prior Authorization. Step 3: Find and complete forms. Step 4: Submit a PA request. Step 5: Check the status of an authorization.

How do I get a prior authorization from BCBS AZ?

Step-by-Step Guide to Completing the BCBSAZ Prior Authorization Form Step 1: Download the Prior Authorization Form. Step 2: Provide Patient Information. Step 3: Enter Provider Details. Step 4: Specify the Requested Service. Step 5: Justify Medical Necessity. Step 6: Submit the Form.

Who is responsible for obtaining preauthorization?

Studies show the average cost for prior authorization approval on primary care practices ranged from $2,161 to $3,430 annually per full-time physician. In addition to the impact on physicians, prior authorization requirements have been found to harm patient care.

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How to get a prior authorization form?

To receive coverage for a medication requiring prior authorization, you can: Ask your healthcare provider to submit the request. Your healthcare provider can submit the request online, by fax or phone by accessing our providers prior authorization information. Submit your own prior authorization request.

What type of health plan is Health Choice Arizona?

As a Medicaid program, BCBS Health Choice offers affordable healthcare to individuals and families who qualify based on income. This program covers many medical needs, from regular doctor visits to mental health services.