BlueCard® (out-of-area) members: Use the pre-service review tool in the secure provider portal at azblue.com/providers.
Precertification is not a guarantee of payment.
Precertification requirements are subject to change without notice.
Precertification approval decisions are based on information provided during the request process. To complete a precertification, medical records might be required.
Although precertification 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 secure provider portal at azblue.com/providers: eligibility and benefits inquiry (includes benefit plan summaries), InterQual® clinical criteria search, and the Clear Claim Connection™ (C3) code edit transparency tool.
Precertification requirements are determined and governed by the member’s benefit plan. Some large groups customize their precertification requirements. Refer to the precertification requirements PDF for these groups.
Penalties: If a required precertification 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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