BCBSAZ makes reasonable effort to keep the lookup tool and code lists current. However, new drugs, devices, and codes (“items”) are released into the market at a rapid pace. Changed codes are also released with some frequency. BCBSAZ reserves the right to require prior authorization for such newly released and changed items even though the tool and code lists have not yet been updated to include them. If you have questions about a newly released or changed item, or whether prior authorization is required, please call us at 602-864-4320 or 1-800-232-2345.
Prior authorization is not a guarantee of payment.
Prior authorization requirements are subject to change without notice.
Prior authorization approval decisions are based on information provided during the request process. To complete a prior authorization, medical records might be required.
Although prior authorization may not be required for a particular service, the claim for the service may still be subject to review for medical necessity, as well as benefits, limitations, exclusions, and waivers, if applicable. For further predetermination research, you can use the following resources in the BCBSAZ secure provider portal: eligibility and benefits inquiry (includes benefit plan summaries), InterQual® clinical criteria search, and the Clear Claim Connection™ (C3) code edit transparency tool.
Penalties: If a required prior authorization is not obtained prior to service, a penalty is applied to: A) the contracted servicing provider or facility, or B) the member, if an out-of-network provider or facility is used.
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