Prior Authorization 

Requests for services that require prior authorization can be submitted on the Prior Authorization form directly through the secure provider portal or via fax to the 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 our 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.

Prior Authorization Grid - effective 5/1/2026
Prior Authorization Grid - effective 1/12/2026
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
Prior Authorization Grid – effective 1/5/2024
Prior Authorization Grid – effective 1/5/2024

Medication Prior Authorization Criteria
Clinical Practice Guidelines

• Medical PA Phone: 1-800-322-8670
• Medical PA Fax Line: 1-877-422-8120
• Medical Referral Fax Line: 1-855-432-2494
• Pharmacy PA Fax Line: 877-422-8130

PA and Continued Stay Review Form for Psychiatric Hospitals and Sub-Acute Facilities
BHIF, BHRF, TFC, and SUD BHRF Prior Authorization and Continued Stay Request Form
Notification of Admission, Transfer and Discharge for Out of Home Placements

Click here to access Prior Authorization Forms.

You can also view the status of previously submitted requests on the Provider Portal.

Requests for dental services that require prior authorization can be submitted through our secure provider portal, by email to HCHdentaldeptHCA@azblue.com, or by mail to:

Blue Cross Blue Shield of Arizona Health Choice
Attn: HC Dental Prior Authorization
8220 N. 23rd Ave.
Phoenix, AZ 85021

Dental Prior Authorization Codes List – effective 1/1/2025
Dental Prior Authorization Codes List – effective 1/1/2026

You can review our 2025 Prior Authorization metrics report here.

We are partnered with EviCore for radiology benefits management of select MR, CT, PET, ultrasound and cardiac imaging studies.

• EviCore Quick Reference Guide
• Migration Quick User Guide
• General Provider Orientation Migration

To submit a new request for imaging services and select cardiac testing/procedures, contact EviCore by:

Phone: 888-693-3211
Fax: 888-693-3210
Provider Portal: https://www.evicore.com/pages/providerlogin.aspx