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.
Prior authorization requirements are determined and governed by the member’s benefit plan. Some large groups customize their prior authorization requirements. Refer to the prior authorization requirements PDF for these groups.
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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