Prior Authorization (PA) is a process by which the AHCCCS Division of Fee-For-Service (FFS) Management (DFSM) determines in advance whether a service that requires prior approval will be covered, based on the initial information received. PA may be granted provisionally (as a temporary authorization) pending the receipt of required documentation to substantiate compliance with AHCCCS criteria.
PA does not guarantee payment. Reimbursement is based on the accuracy of the information received with the original PA, on whether or not the service is substantiated through concurrent and/or medical review, and on whether the claim meets claims submission requirements. (See AMPM 820)
The following services are not handled by DFSM. You must contact the appropriate entity for authorization:
- Non-Acute Services for Tribal ALTCS Program members - contact Tribal Case Manager.
- Transplant Services - contact Medical Management in the AHCCCS Division of Health Care Management (DHCM).
- Prescription Medication - contact the contracted Pharmacy Benefit Manager (PBM), Optum Rx at (855) 577-6310.
- Behavioral Health PA Requests for Acute FFS members assigned to the RBHA – contact the RBHA.
Preferred Method of Submission
The AHCCCS Online Provider Portal is the preferred method of submitting Prior Authorization requests for Fee-For-Service members. Online submission allows the DFSM staff to process authorization requests efficiently and quickly. Providers who would like immediate information, can also access the provisional authorization number and track the authorization status in real time in the provider portal.
Education and Training Questions
The DFSM Provider Education and Training Unit can assist providers with the following:
- How to submit and status claims or prior authorization requests through the AHCCCS Online Provider Portal (FFS programs, including AIHP, TRBHAs and Tribal ALTCS)
- Submission of documentation using the Transaction Insight Portal (e.g., The AHCCCS Daily Trip report, requested medical records, etc.)
The DFSM Provider Education and Training Unit does not instruct providers on how to code or bill for a particular service. The DFSM Provider Training Team can be outreached at email@example.com.
Providers should use the online website as the first step in checking the status of the prior authorizations. Our Provider Services representatives are skilled to provide help to many basic prior authorization questions. To reach Provider Services call (602) 417-7670.
Provider Services Operation Hours:
Monday-Friday from 7:30 A.M. - 5:00 P.M.