Welcome to Our Family!

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 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 prior authorizations or Clinical Guidelines information, Member Services can help you. Call us at 1-800-322-8670 (TTY 711). We are open 8 a.m. – 5 p.m., Monday-Friday (except holidays). You can also contact us by e-mail at HCHComments@azblue.com.

Prior Authorization Grid - effective 10/1/2025
Prior Authorization Grid - effective 7/1/2025
Prior Authorization Grid - effective 4/10/2025
Prior Authorization Grid – effective 3/1/2025

There may be a time when you are so sick that you cannot make a decision about your own health care. You, or a representative chosen by you, have the right to make decisions to withhold resuscitative services, or to forgo or withdraw life-sustaining treatment within the requirements of Federal and State law with respect to advance directives [42 CFR 438.6].

An Advance Directive is a paper that protects your right to refuse health care you do not want. It may also tell people about care that you do want.

There are four types of Advance Directives:

1. Living Will (End of life care)
2. Medical Power of Attorney
3. Mental Healthcare Power of Attorney
4. Pre-Hospital Medical Directive (Do Not Resuscitate)

We respect your right to make decisions about your health care and thinks that it is important for you to have one or more of these papers.

A Living Will is a piece of paper that tells doctors what types of services you do or do not want if you become very sick and near death and may not be able to make health care decisions or give consent for yourself. For example, in your Living Will you might tell doctors if you want to be kept alive with machines or fed through tubes if you cannot eat or drink on your own.

A Medical Power of Attorney is a paper that lets you choose a person to make decisions about your health care when you cannot do it yourself.

A Mental Healthcare Power of Attorney names a person to make decisions about your mental health care if it is found that you cannot.

A Pre-Hospital Medical Care Directive tells providers if you do not want certain lifesaving emergency care that you would get outside a hospital or in a hospital emergency room. You must complete a special orange form. You can get a free copy of this form by calling the Bureau of Emergency Medical Services at 602-364-3150.

You should get help writing your Living Will and Medical Power of Attorney. Ask your doctor for help if you are not sure who to call.

Making Your Advance Directives Legal

For both a Living Will and a Medical Power of Attorney, you must choose someone who will make decisions about your health care if you cannot. This person can be a family member or a close friend and is called your agent.

To make an Advance Directive legal, you must:

1. Sign and date it in front of another person, who also signs it.
   This person cannot:
   • Be related to you by blood, marriage or adoption;
   • Have a right to receive any of your personal and private property upon death;
   • Be appointed as your agent; or
   • Be your healthcare provider.
2. Sign and date it in front of a Notary Public. The Notary Public cannot be your agent or any person involved with the paying of your health care.

If you are too sick to sign your Medical Power of Attorney, you may have another person sign for you.

After you Complete your Advance Directives

• Keep your original signed papers in a safe place.
• Give copies of the signed papers to your doctor(s), hospital, and anyone else who might become involved in your health care. Talk to these people about your wishes concerning your health care.
• If you want to change your papers after you have signed them, you must complete new papers. You should make sure you give a copy of the new paper to all the people who already had a copy of the old one.
• Be aware that your directives may not be effective in a medical emergency.
• Source of Additional Information and Forms

The following organization provides health care directive forms and information:

Division of Aging and Adult Services
State of Arizona
1789 W. Jefferson, Site Code 950A Phoenix, AZ 85007
Phone: (602) 542-4446
Visit their website

Your local Area Aging and Senior Center may also have forms and information.

If you have complaints about your right to make health care decisions, you may contact us at 1-800-322-8670.

It is very important for you to decide what treatment you do or do not want.

• Give copies of your Living Will and/or Medical Power of Attorney to your doctor, hospital and any other people involved with your health care.
• You should get help writing your Living Will/or Medical Power of Attorney. Ask your doctor for help if you are not sure whom to call.
• If you change any part of your Living Will or Medical Power of Attorney, you should make sure you give a copy of the new one to all the people who already had a copy of the old one.

To read more on Arizona state laws on Advance Directives, visit Life Care Planning | Arizona Attorney General (azag.gov)

MEMBER RIGHTS
COMPLIANCE WITH FEDERAL AND STATE LAWS

Blue Cross Blue Shield of Arizona Health Choice complies with all federal and state laws, including:

• Title VI of the Civil Rights Act of 1964 as implemented by regulations at 45 CFR part 80.
• The Age Discrimination Act of 1975 as implemented by regulations at 45 CFR part 91.
• The Rehabilitation Act of 1973
• Title IX of the Education Amendments of 1972 (regarding education programs and activities), Titles II and III of the Americans with Disabilities Act; and section 1557 of the Patient Protection and Affordable Care Act

Please note: Complaints should go to the Clinical Resolution Unit (CRU). To file a complaint with AHCCCS, please call the Clinical Resolution Unit within Maricopa County at 602-364-4558 or statewide at 1-800-867-5808.

As a Blue Cross Blue Shield of Arizona Health Choice member, you have the right to:

• You have the freedom of choice among providers within our network.  
• Choose a primary care provider (PCP) and other providers from our network list. This also includes the right to refuse care from providers.  
• Use any hospital or other setting for emergency care.
• Get a second opinion from a qualified health care professional within the network or have a second opinion arranged outside of the network, only if there is not adequate in-network coverage, at no cost.   
• Privacy and to be treated with respect and dignity.
• Your care:
  • The member’s right to be treated fairly regardless of disability, race, color, ethnicity, national origin, religion, gender, age, sex, gender identity, behavioral health condition (intellectual) or physical disability, sexual orientation, genetic information, or ability to pay.
  • The member’s right to develop a contingency plan with their provider agency to decide their preferences for each service, subject to Electronic Visit Verification (EVV) and provided by the provider when a service visit is short, late, or missed.
  • Receive and discuss information on available treatment options and alternatives, regardless of cost or benefit coverage; presented in a manner appropriate to your condition and in a way you can understand.  
  • Get health care services in accordance with access to care and quality standards.
  • Create a plan that tells health care providers what kind of treatment you do or do not want if you become too sick to make your own health care decisions. These are advance directives.  
  • Be free from any form of control or isolation used as a means of force, authority, convenience, or retaliation. You cannot be held against your will. You cannot be forced to do something you do not want to do. This also means you have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.  
  • Understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible  
  • Make decisions about your health care. This includes agreeing to treatment. It can also include the right to refuse treatment.  
• You have the right to get other information, such as:  
  • Covered services and how to get covered services that are not offered or available through the health plan.
  • How to get after-hours and emergency services.  
  • Available treatment options (including the option of no treatment).  
  • Beneficiary and plan information.
  • Prior authorization, referrals or any special procedures needed to get medical services. 
  • How to get mental health or substance abuse services.  
  • How to get services outside our service area.  
  • Its practitioners and providers.  
  • The plan’s provider incentive program: This means you can ask about ways that the health plan pays our providers. Providers or other health care professionals are not financially rewarded based on denial of care or for limiting services.  
  • Its quality improvement program including member survey results for the health plan.  
• The right to family planning services from an appropriate registered provider.  
• A description of how the organization evaluates the appropriate use of new developments in medical technology and new applications of existing technologies for inclusion as a covered benefit.  
• New medical devices and procedures are evaluated by our medical management team to:  
  • Keep abreast of ongoing changes in medical technology. 
  • Ensuring our members have safe, effective, and evidence-based care. 
  • Review information from the appropriate governmental regulatory bodies such as U.S. Food and Drug Administration (FDA) 
  • Obtain input from specialists and professionals with unique knowledge about the specific technology reviewed. 
• Structure and operation of Blue Cross Blue Shield of Arizona Health Choice or its subcontractors.
• Whether or not we have Physician Incentive Plans (PIP) that affect the use of referral services and the right to a summary of member survey results, in accordance with PIP regulation.
• Whether stop-loss insurance is required.
• Grievances, appeals and requests for a State Fair Hearing.
• Medical Records:
  • Inspect your medical records at any time. You have the right to ask for a copy of your medical records at least annually. There is no cost to you. 
  • You have the right to a written reply from us within 30 days of your request for medical records. 
  • If denied, you have the right to information about why your request was denied.  
  • You have the right to seek review of a denial in accordance with 45 CFR Part 164.  
  • You have the right to change or correct your medical records. 
  • Request restrictions.  
• Private communications.
• Accounting of disclosures.  
• Have services and materials provided in a way that helps you understand. This may include help with:  
  • Language Needs: Language services are available to you at no cost. This includes interpretation and translation. It also includes having materials translated into your own language. This includes having materials translated into your own language. We can help you find providers who speak your language. If your provider does not speak your language, they will arrange an interpreter for your medical appointments. This is provided at no cost to you. Talk to your provider about language services.  
  • Visual Needs: This may include recorded materials, such as a CD, or materials in Braille. You can also ask for larger print. This is provided at no cost to you. Call Member Services for more information.  
  • Hearing Needs: If you are deaf or hard of hearing, you can call Arizona Relay Services at 711. This telephone relay, or TTY/TDD, is a free public service. There is no cost to you. We can also get you a sign language interpreter for your medical appointments. This is provided at no cost to you. Call Member Services for more information. 
• To maintain compliance with all Federal and State regulatory bodies and Accrediting agencies applicable to Blue Cross Blue Shield of Arizona Health Choice plans.
• Complain about Blue Cross Blue Shield of Arizona Health Choice. This complaint or appeal can be filed with us or AHCCCS. You cannot be denied services if you file a complaint.  
• A paper copy of the Notice of Privacy Practices. See the “Your Privacy” section of this handbook for more information.  
• You have the right to make recommendations regarding the organization’s member rights and responsibilities policy.
• Confidentiality and your privacy are important to us. Please see the Notice of Privacy Practices included in the next section or in your Member Welcome Kit for information on how we handle medical information. 
• Be sure Blue Cross Blue Shield of Arizona Health Choice will not hold it against you if you choose to use any of your rights.

 

Members are in charge of taking care of their AHCCCS ID card. Using the card in a way that is wrong, such as loaning, selling, or giving it to someone else could result in the loss of eligibility and/or legal action as applied by Federal or State law (42 CFR 455.2). If you witness any misuse of any ID card or any other type of fraud or abuse please contact Member Services immediately at 480-968-6866.

FRAUD is any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself/herself or some other person. It includes any act that constitutes fraud under applicable Federal or State law (42 CFR 455.2).

ABUSE (of member) means provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to the DWS program; or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the DWS program (42 CFR 455.2).

What if I know of or think there may be Medicaid fraud?

Medicaid PROVIDER Fraud: If you think a Medicaid provider is involved with fraud, please contact Member Services immediately at 480-968-6866 (Maricopa County) or toll-free at 1-800-322-8670, 8 a.m. – 5 p.m., Monday-Friday (except holidays).
Email: HCHComments@azblue.com

Medicaid CLIENT Fraud: If you think a Medicaid client is involved with fraud, please contact:
Department of Workforce Services Payment Error Prevention Unit
Email: HCHComments@azblue.com

If you have questions or concerns about your health care, doctors, covered services, or care you are receiving please call Member Services at 1-800-322-8670.

The Member Services Department can help you with many questions like these:

• Determine financial responsibility for a drug, based on the pharmacy benefit
• Check the status on denials or appeals [Or, Initiate the exceptions process (for Medicare)]
• Order a refill for an existing, unexpired mail-order prescription
• Find the location of an in-network pharmacy [in close proximity based on zip code search
• Determine the availability of generic substitutes

For more information about your Pharmacy benefit, you may also see our Pharmacy Services page.

If you have a question about prior authorizations, Member Services can help you, call us at 1-800-322-8670 (TTY 711). We are open 8 a.m. – 5 p.m., Monday-Friday (except holidays).

You can also contact us by e-mail at HCHComments@azblue.com

Your PCP is in charge of all your health care needs. If needed, your PCP may recommend a specialist and may make the appointment for you, or we can assist you with making the appointment. You can also refer to the provider directory to find a network specialist.