Ariz. Admin. Code § R20-5-1303 - Provider Request for Preauthorization

A. No preauthorization is required under the Act to ensure payment for reasonably required medical treatment or services. While preau-thorization is not required under the Act, a provider may seek preauthorization as provided in this subsection.

B. A provider shall submit a request for preauthorization in writing using Section I (Provider Request for Preauthorization) of the Medical Treatment Preauthorization Form approved by the Commission under R20-5-106(A)(12). A provider shall attach documentation to a request for preauthorization that supports the medical necessity and appropriateness of the treatment or services requested, such as office notes and diagnostic reports.

1. Patient information (including date of injury, date of birth, and payer claim number);

2. Diagnosis and ICD code;

3. Date of request;

4. Type of request - Initial, Routine, Urgent, or Life Threatening;

5. A statement of the treatment or services requested. Where appropriate, information about quantity, strength, duration and frequency of the treatment or services should be included. Use of the applicable codes should also be included and will facilitate the process; and

6. Documentation, if not already provided, that supports the medical necessity and appropriateness of the treatment or services requested, such as office notes and diagnostic reports.

C. A provider may submit the request for preauthorization by mail, electronically or by fax.

Notes

Ariz. Admin. Code § R20-5-1303

Adopted by final rulemaking at 22 A.A.R. 1730, effective 10/1/2016. Amended by final rulemaking at 24 A.A.R. 2069, effective 10/1/2018.