Douglas A. Ducey, Governor
Jami Snyder, Director
801 E. Jefferson, Phoenix, AZ 85034
PO Box 25520, Phoenix, AZ 85002
Phone: 602-417-4000
www.azahcccs.gov
FEE-FOR-SERVICE PRIOR AUTHORIZATION
MEDICAL DOCUMENTATION FORM
◊ Mandatory fields must be completed or form will be returned.
AHCCCS does not require authorization when Medicare or other insurance is primary.
ONE MEMBER AND PROVIDER PER FORM, PER FAX PLEASE
◊ RECIPIENT NAME:
◊ PROVIDER NAME:
◊ AUTHORIZATION #:
◊ PROVIDER PHONE #:
◊ PROVIDER FAX #:
◊ AHCCCS ID (9 d
igits): A
◊ PROVIDER
NPI
(10
digits
):
◊ PROV
AHCCCS
ID
(
6
digits
):
◊ DATES
OF
SERVICE:
◊ COMMENTS:
TYPE OF DOCUMENTATION SUBMITTED
Prior Authorization (602) 256-6591
Utilization Review (602) 254-2304
Transportation (602) 254-2431
BHS (602) 253-6695 (Primary)
For urgent requests, call us at (602) 417-4400. If this form was received in error, contact the submitting Provider
immediately.
LTC (602) 254-2426
BHS (602) 364-4697
(Alternate)
(Revised 7/16/19)
Utilization Review (Required
Documentation)
HSAG
Prior Authorization
CRS DME
FESP Dialysis Home Health
Home Infusion Lodging/Meals
Observation Reconsiderations
Transportation
BH NEMT
Medical NEMT
LTC Acute
Hospice
NF/Reviews
BH Inpatient & RTC
Other
GR TRBHA
NN TRBHA
PY TRBHA
WM TRBHA
Other
BH Residential Facilities
AIHP
GR TRBHA
NN TRBHA
PY TRBHA
WM TRBHA
Tribal ALTCS Authorization
Assisted Living Facility – BH
DME
Home Modifications
NF/Reviews/Special Rates
*ALTCS: The following documentation must be sent to the Tribal Case Manager:
*Return fax #
*HCBS *Hospice
*DME <$500 and Purchase *Supplies < $100 *Transport *Rentals
E1399
Ou
t of State
>80% CES
Contractor Change
Non/Fair Hearing
Member Issue
Open Line Request
Concurrent Review Denials
Retro Review Denials
History an
d Physical
Surgery/Procedure Reports MD
Orders & Progress Notes IV
Meds & Actual Frequencies
AIHP
Enrollment Transition
Information (ETI) /
Transition of Care (TOC)
Concurrent
Retro
ETI/TOC
