Ma Provider Azblue Prior Authorization Request Form 508 En.Pdf Form

AZ Blue Standard requests–fax to 602-544-5652 Post-acute care, behavioral health, and concurrent reviews–fax to 602-544-5654 Expedited requests–fax to 602-544-5651 Part B drugs–fax to 602-544-5622 Inpatient notifications–fax to 602-544-5653 After-hours phone number for immediate services–call 1-888-905-1172 TYPE OF REQUEST (Required) Notification Urgent/emergency inpatient admission Prior Auth–Standard Elective admission or services to be scheduled within 30 days (prior authorization date ranges may vary) Prior Auth–Expedited Provider certifies that applying the standard review time frame may seriously jeopardize the member’s life, health, or ability to recover, or result in serious impairment or permanent disability Prior Auth–Part B Drug Drugs covered under medical benefits and usually administered by a healthcare professional Prior Auth–Post-Acute Care Transition to non-acute care setting (SNF, EAR, LTAC, home health); projected date of transition (mm/dd/yyyy) /
/ Concurrent Review Submission of clinical documentation for ongoing acute or post-acute care Patient/Member Name (First) Last MI Phone Number Patient DOB (mm/dd/yyyy)

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Member ID # (including prefix) Provider Name TIN Specialty Contact Name Phone NPI# Fax Group Name Group Address City, State, ZIP Phone Fax Provider Name TIN Specialty Contact Name Phone NPI# Fax Is servicing provider in-network for this member’s benefit plan?
Yes
No Group/Facility Name (if different from above) TIN Address NPI# City, State, ZIP Phone Fax

2. MEMBER/PATIENT INFORMATION (Required)
3. ORDERING PROVIDER (Required)
4. SERVICING PROVIDER (Required) AZ BLUE MEDICARE ADVANTAGE PRIOR AUTHORIZATION REQUEST FAX FORM (for Medicare Advantage plans) For AZ Blue-administered plans, request prior authorization from eviCore for medical oncology, radiation therapy, high-tech radiology, genetic testing, spine/joint surgeries, and interventional pain management services (use the online request tool at eviCore.com). For all other services, fax this form and clinical records to AZ Blue at the applicable number below. Select the plan administrator below (as displayed on the back of the member ID card) and fax this form and clinical records to the appropriate fax number. OptumCare Arizona ONLINE: https://providers.optumcaremw.com FAX: 1-888-992-2809 PHONE: 1-877-370-2845
5. DATE AND TYPE OF REQUEST (MM/DD/YYYY) / / Arizona Priority Care (AZPC) Services, items, and Part B drugs-fax to 480-499-8798 (or online at AZconnect) Inpatient notifications/concurrent review-fax to 480-499-8779 After-hours phone number for immediate services-call 480-499-8700

ICD-10 Code(s): ICD-10 Descriptions: HCPCS/CPT/CDT Code Code Description Units Frequency Requested

7. CODING (Required, except for inpatient notifications) Type of Service: Name of Therapy/Agency: Units/Visits Requested: Frequency/Length of Time Needed: Initial Prior Authorization #: Extension Additional Comments:
8. ADDITIONAL TYPES OF SERVICE NEEDED Diagnosis name and code: Medication Requested Strength Dosing Schedule Quantity/Frequency Is the patient currently treated with requested medication(s)?
   Yes
   No If yes, when was treatment with the requested medication started? (mm/dd/yyyy) / / Explain the medical reason for requested medication, including an explanation for selecting this medication over alternatives: List any other medications the patient will use in combination with requested medication:
9. MEDICATION(S) (covered under medical benefits) Please attach required documentation for medical necessity evidence and concurrent reviews, including relevant patient history and physical, physician consult notes, lab data, imaging and procedure reports, progress notes, discharge summary (if available), recent PT/OT evaluations, or other relevant information (e.g., change in condition/ status). Requests submitted without appropriate clinical documentation may be denied. Comments:
10. CLINICAL DOCUMENTATION SAVE and FAX this form, along with clinical records documenting evidence of medical necessity, to AZ Blue, OptumCare Arizona, or AZPC at the fax numbers listed on the top of page 1. Y0137Y25603PY20C 1559258-24 PRIOR AUTHORIZATION REQUEST FAX FORM (for AZ Blue Medicare Advantage plans)
11. PLACE OF SERVICE (if applicable) Place of Service:
    Office Outpatient
    Inpatient
    Home Other Please specify if other:
12. MEDICAL NECESSITY DURATION (Required) How long will this service or DME be medically necessary?
    90 Days 180 Days 365 Days (If not indicated, we will use the shortest duration for the prior authorization.)