Prior Authorization and Clinical Guidelines

Blue Cross Blue Shield of Arizona Health Choice uses clinical practice guidelines when making important decisions about keeping you and your family healthy.

We provide the support needed to be sure your primary care provider, specialists, and other healthcare providers involved in your care work closely with you on treatment plans for individual needs.

We encourage members to call Member Services at 1-800-322-8670 with specific questions relating to your care.

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.

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 we will cover the cost of the service.

A PA request is a form your provider fills out and sends it to us. 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 1-800-322-8670 (TTY 711). Our Member Services department is open 8 a.m. to 5 p.m., Monday - Friday. You can also contact us by e-mail at HCHComments@azblue.com.