Prior Authorization & Clinical Guidelines

Last Updated: November 15, 2023 at 7:56 am

At BCBSAZ Health Choice Pathway HMO D-SNP, our goal is to work closely with you and your practice team to streamline and expedite prior authorization. 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.

Prior Authorization Guidelines

Requests for services that require prior authorization can be submitted on the BCBSAZ Health Choice Pathway Prior Authorization form by fax or requests can be phoned into the Health Choice Prior 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

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, 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

Annual Medicare Model of Care Training

Annual Medicare Model of Care Training 2019 – 2020
(Updated - 02/26/2020 01:54 PM)
Annual Medicare Model of Care Training 2018 – 2019
Annual Medicare Model of Care Training – 2018
Annual Medicare Model of Care Training – 2017

BCBSAZ Health Choice Pathway utilizes:

• Inter-Qual
• UpToDate

Adult Hypertention 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

Chironic Pain Management Guidelines (American Pain Society)

Clinical Practice Guidelines

Diabetes Management Guidelines (ADA)

Clinical Practice Guidelines

General Infections Disease Management Guidelines (IDSA)

Clinical Practice Guidelines

HIV Management Guidelines

CDC/NIH
IDSA

Smoking Cessation Guidelines (NIH)

Tobacco Cessation