Utilization Management

Authorization Requirements

• Authorization is required for hospital admissions and certain specialty services, including outpatient services.
• Prior Authorization is obtained by means of a completed Prior Authorization Form.
• Failure to secure prior authorization before rendering services may result in denial of claims payment.

Affirmative Statement About Incentives

• Utilization Management (UM) decision-making is based only on the appropriateness of care and service existence of coverage.
• The organization does not specifically reward practitioners or other individuals for issuing denials of coverage or service care.
• Financial incentives for UM decision-makers do not encourage decisions that result in under-utilization

Availability of UM Criteria Guidelines

Members, Authorized Representatives, and Practitioners may request a copy of the criteria guidelines used in making UM determination in the following methods during our business hours (Monday – Friday, 8:00 AM to 5:00 PM):

• Telephone: 480-499-8700 Ext. 8301 (TTY 711)
• Fax: 480-499-8798
• Email: priorauthdepartment@azprioritycare.com
• In-person: 585 N. Juniper Dr., Suite 150, Chandler, AZ 85226

Prior Authorization Resources

• Prior Authorization Request Form
•  Part B Drug Prior-Authorization Request Form
•  Medicare Part B vs Part D-CMS2015
•  Services that Do Not Require Auth
•  Diabetic Testing Supply Order Form
•  AZPC Plan Redirect Form
• 2024 UM Program