Prior Authorizations & Referrals

If Prior Authorization (PA) is required, the Primary Care Provider (PCP) or specialty care provider will complete the Prior Authorization Form, attach supporting documentation and fax to the Prior Authorization Department. Some medications (including non-generic medications) require Prior Authorization. To request an authorization for a medication that is not listed on the formulary but is reimbursable, please complete a non-formulary drug prior authorization and fax to the number listed within the Pharmacy Prior Authorization Form (see below).

  • Services that are outside the scope of the PCP, may be referred to a contracted specialty care provider. The PCP will complete the Referral Form or acceptable substitute and fax it to the specialty care provider’s office along with applicable test results and other pertinent documents.
  • Primary care providers, specialists, hospitals, and vendors should fax Prior Authorization requests to the Prior Authorization Department.
  • If PA is not required, per the Prior Authorization Grid, the PCP must refer the patient with a form of written instruction (i.e., note on prescription pad or Referral Form) with reason for visit (consult only – consult & treat, diagnosis, findings, etc.) to present to the specialty care provider.
  • Specialty care providers must obtain Prior Authorization from the Prior Authorization Department for all services as listed on the Prior Authorization Grid.

Changing Prior Authorization Process

Prior authorization processes will be changing for some of your patients. Banner Health has contracted with eviCore healthcare to provide services for members enrolled in Banner – University Family Care/ACC and Banner – University Family Care/ALTCS. Learn more at the links below!

Submitting for Prior Authorization

For increased efficiency and advanced Prior Authorization experience, please submit your PA electronically! 

Electronic prior authorization (ePA) helps you spend less time on PA’s and more time on patients. Some Electronic Health Records come equipped with ePA, but if yours doesn’t, there are online options such as Surescripts, CoverMyMeds, and ExpressPAth. 

Learn about and submit your PA to an online ePA portal here.

*Providers must use the “Expedited” request only when medically necessary.

Prior Authorization Forms

Please include ALL pertinent clinical information with your Medical/Pharmacy Prior Authorization (PA) request submission. To ensure that prior authorizations are reviewed promptly, submit request with current clinical notes and relevant lab work.


Related Documents 

Behavioral Health Prior Authorization Form

Medical Prior Authorization Form

Pharmacy Prior Authorization Form

Retrospective Review

Please submit a Retrospective Review Request Form when good cause can be shown why pre-service authorization did not occur prior to services being rendered and/or lack of notification or timely notification for an emergent inpatient admission. It may be possible to get resolution without going through a formal appeal process and minimize administrative burden for your claim submission.
  
Complete and follow the instructions in the Retrospective Review Form below. If it is determined the request is eligible for review, a decision will be made within 30 calendar days following receipt of your request.


Related Documents

PRIOR AUTHORIZATION GRIDS

Services Requiring Prior Authorization

The Prior Authorization Grids are your source for determining what services require Prior Authorization. Be sure to reference the date of the grid since revisions to the grid may occur.

Always refer to the AHCCCS Medical Policy Manual (AMPM) Chapter 300 for coverage issues:

https://www.azahcccs.gov/shared/MedicalPolicyManual/