Ariz. Admin. Code § 21-1-204

Current through Register Vol. 30, No. 25, June 21, 2024

Section R21-1-204 - Prior Authorization

A. Healthcare providers may be required to obtain authorization from DCS CHP or delegated entity before services are rendered in order for those services to be paid for under this Article and A.R.S. § 8-512.

B. DCS CHP shall not pay for any health service that requires prior authorization and was:

1. Not submitted for prior authorization; or

2. Submitted but prior authorization is not granted.

C. Healthcare providers shall obtain prior authorization from DCS CHP for certain services according to the provisions of A.R.S. Title 36, Chapter 29, Article 1, and 9 A.A.C. Chapter 22, Article 1.

D. In instances where a prior authorization is required for a service but not obtained by the Healthcare provider, the Healthcare provider shall not submit a claim or invoice for a service to any party, including:

1. The Department;

2. The Department's representatives;

3. Any delegated entity the Department may contract with to administer this program;

4. The DCS CHP Member; or

5. The DCS CHP Member's;

a. Guardian,

b. Custodian,

c. Estate,

d. Foster Parent, or

e. Birth parent.

Ariz. Admin. Code § R21-1-204

Adopted by exempt rulemaking at 21 A.A.R. 2554, effective 11/30/2015. Amended by final rulemaking at 27 A.A.R. 2518, effective 10/5/2021.