Prior Authorization and Clinical Guidelines

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).

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 1-800-656-8991 (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.

You can review our Prior Authorization metrics report here.

American College of Cardiology/American Heart Association

Centers for Disease Control and Prevention (CDC)

• Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children – PMC

American Psychiatric Association

• Practice Guideline for the Treatment of Patients with Major Depressive Disorder
• Major depressive disorder: Validated treatments and future challenges - PMC (nih.gov)

American Academy of Neurology (AAN)

• Practice Guideline Update: Acute Treatment of Migraine in Children and Adolescents
• Practice Guideline Update: Pharmacologic Treatment for Pediatric Migraine Prevention

American Academy of Pediatric Dentistry (AAPD)

• Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents