You must try arranging your own transportation to and from your medical appointments. You must try to use your own car, take the bus, or have a family member or friend give you a ride. If you cannot drive yourself or cannot afford to take a bus or taxi, Health Choice will arrange one for you. (NOTE: SOBRA Family Planning members are not covered for any type of transportation services).
If you have an urgent appointment due to an immediate health condition, please contact Member Services at 1-800-322-8670 (TTY 711).
Important Information for Members
Some medical tests or services require prior authorization before they are scheduled. Your provider requests prior authorization on your behalf. A prior authorization, commonly called a ‘PA’, is not a promise Health Choice will cover the cost of the service.
A PA request is a form your provider fills out and sends to Health Choice. Our prior authorization department will review the request and make a decision. A decision for a standard request is made within 14 calendar days and a decision for an expedited request is made within 3 calendar days. You and your provider will be notified if the service is approved or denied.
If you have a question about prior authorizations, Member Services can help you. Call us at 1-800-322-8670 (TTY 711). Our Member Services Department is open 8 a.m. – 5 p.m., Monday-Friday (except holidays). You can also contact us by e-mail at HCHComments@azblue.com.
Prior Authorization Grid – effective 11/05/2022
Medication Prior Authorization Criteria
Clinical Guidelines Information
There may be a time when you are so sick that you cannot make a decision about your own health care. You, or a representative chosen by you, have the right to make decisions to withhold resuscitative services, or to forgo or withdraw life-sustaining treatment within the requirements of Federal and State law with respect to advance directives [42 CFR 438.6].
An Advance Directive is a paper that protects your right to refuse health care you do not want. It may also tell people about care that you do want.
There are four types of Advance Directives:
- Living Will (End of life care)
- Medical Power of Attorney
- Mental Healthcare Power of Attorney
- Pre-Hospital Medical Directive (Do Not Resuscitate)
BCBSAZ Health Choice respects your right to make decisions about your health care and thinks that it is important for you to have one or more of these papers.
A Living Will is a piece of paper that tells doctors what types of services you do or do not want if you become very sick and near death and may not be able to make health care decisions or give consent for yourself. For example, in your Living Will you might tell doctors if you want to be kept alive with machines or fed through tubes if you cannot eat or drink on your own.
A Medical Power of Attorney is a paper that lets you choose a person to make decisions about your health care when you cannot do it yourself.
A Mental Healthcare Power of Attorney names a person to make decisions about your mental health care if it is found that you cannot.
A Pre-Hospital Medical Care Directive tells providers if you do not want certain lifesaving emergency care that you would get outside a hospital or in a hospital emergency room. You must complete a special orange form. You can get a free copy of this form by calling the Bureau of Emergency Medical Services at 602-364-3150.
You should get help writing your Living Will and Medical Power of Attorney. Ask your doctor for help if you are not sure who to call.
Making Your Advance Directives Legal
For both a Living Will and a Medical Power of Attorney, you must choose someone who will make decisions about your health care if you cannot. This person can be a family member or a close friend and is called your agent.
To make an Advance Directive legal, you must:
- Sign and date it in front of another person, who also signs it.
This person cannot:
- Be related to you by blood, marriage or adoption;
- Have a right to receive any of your personal and private property upon death;
- Be appointed as your agent; or
- Be your healthcare provider.
- Sign and date it in front of a Notary Public. The Notary Public cannot be your agent or any person involved with the paying of your health care.
If you are too sick to sign your Medical Power of Attorney, you may have another person sign for you.
After you Complete your Advance Directives
- Keep your original signed papers in a safe place.
- Give copies of the signed papers to your doctor(s), hospital, and anyone else who might become involved in your health care. Talk to these people about your wishes concerning your health care.
- If you want to change your papers after you have signed them, you must complete new papers. You should make sure you give a copy of the new paper to all the people who already had a copy of the old one.
- Be aware that your directives may not be effective in a medical emergency.
- Source of Additional Information and Forms
The following organization provides health care directive forms and information:
Division of Aging and Adult Services
State of Arizona
1789 W. Jefferson, Site Code 950A Phoenix, AZ 85007
Phone: (602) 542-4446
Your local Area Aging and Senior Center may also have forms and information.
If you have complaints about your right to make health care decisions, you may contact the BCBSAZ Health Choice Member Services Department at 1-800-322-8670.
It is very important for you to decide what treatment you do or do not want.
- Give copies of your Living Will and/or Medical Power of Attorney to your doctor, hospital and any other people involved with your health care.
- You should get help writing your Living Will/or Medical Power of Attorney. Ask your doctor for help if you are not sure whom to call.
- If you change any part of your Living Will or Medical Power of Attorney, you should make sure you give a copy of the new one to all the people who already had a copy of the old one.
As a BCBSAZ Health Choice Member, you have the right to:
- Choose a primary care provider (PCP) and other providers from the BCBSAZ Health Choice network list. This also includes the right to refuse care from providers.
- You have the freedom of choice among providers within the BCBSAZ Health Choice network.
- Complain about BCBSAZ Health Choice. This complaint or appeal can be filed with BCBSAZ Health Choice or AHCCCS. You cannot be denied services if you file a
- Request information on the structure and operation of BCBSAZ Health Choice or its
- Request information on whether or not BCBSAZ Health Choice has Provider Action Plans (PIP) that affect the use of referral services, the right to know the types of compensation arrangements BCBSAZ Health Choice uses, the right to know whether stop-loss insurance is required and the right to a summary of member survey results, in accordance with PIP regulation.
- Be treated fairly when getting medical This means you have equal access to all BCBSAZ Health Choice services. BCSAZ Health Choice does not discriminate against any member based on race, ethnicity, national origin, religion, gender, age, behavioral health condition (intellectual) or physical disability, sexual preference, genetic information, or ability to pay.
- All members also have the right to exercise his or her rights and that the exercise of those rights shall not adversely affect service delivery to the member [42 CFR 438.100(c)].”
- A second opinion from a qualified health care professional within the network or have a second opinion arranged outside of the network, only if there is not adequate in-network coverage, at no cost.
- Receive and discuss information on available treatment options and alternatives, regardless of cost or benefit coverage; presented in a manner appropriate to your condition and in a way you can
- Create a plan that tells health care providers what kind of treatment you do or do not want if you become too sick to make your own health care decisions. These are called “advance ” We can give you information to help you create your own advance directives.
- You have the right to get other information, such as:
- How to get after-hours and emergency services
- Available treatment options (including the option of no treatment)
- Prior authorization, referrals or any special procedures needed to get medical services
- How to get mental health or substance abuse services
- How to get services outside the BCBSAZ Health Choice service area
- How to get covered services that are not offered or available through the health plan
- The right to family planning services from an appropriate registered provider
- A description of how the organization evaluates the appropriate use of new developments in medical technology and new applications of existing technologies for inclusion as a covered New medical devices and procedures are evaluated by BCBSAZ Health Choice medical management team to:
- Keep abreast of ongoing changes in medical technology.
- Ensuring our members have safe, effective and evidence-based care.
- Review information from the appropriate governmental regulatory bodies such as U.S. Food and Drug Administration (FDA).
- Obtain input from specialists and professionals with unique knowledge about the specific technology reviewed.
- To maintain compliance with all Federal and State regulatory bodies and Accrediting agencies applicable to BCBSAZ Health Choice plans.
- Information about grievances, appeals and requests for a hearing
- Inspect your medical records at any time. You have the right to ask for a copy of your medical records at least There is no cost to you.
- You have the right to a written reply from BCBSAZ Health Choice within 30 days of your
- If denied, you have the right to information about why your request was
- You have the right to seek review of a denial in accordance with 45 CFR Part
- You have the right to change or correct your medical
- Request restrictions
- Private communications
- Accounting of disclosures
- A paper copy of the Notice of Privacy See the “Your Privacy” section of this handbook for more information.
- You have the right to make recommendations regarding the organization’s member rights and responsibilities policy.
- Ask for information about BCBSAZ Health Choice such as:
- It’s services
- It’s practitioners and providers
- The plan’s provider incentive program: This means you can ask about ways that the health plan pays our Providers or other health care professionals are not financially rewarded based on denial of care or for limiting services.
- It’s quality improvement program including member survey results for the health plan
- Get health care services in accordance with access to care and quality standards
- Be sure BCBSAZ Health Choice Arizona will not hold it against you if you choose to use any of your
- Be free from any form of control or isolation used as a means of force, authority, convenience, or You cannot be held against your will. You cannot be forced to do something you do not want to do. This also means you have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
- Receive information on beneficiary and plan
- Privacy and to be treated with respect and dignity
- Understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
- Make decisions about your health care. This includes agreeing to treatment. It can also include the right to refuse
- Have services and materials provided in a way that helps you understand. This may include help with:
- Language Needs: This includes having materials translated into your own language. We can help you find providers who speak your language. If your provider does not speak your language, they will arrange an interpreter for your medical This is provided at no cost to you. Talk to your provider about language services.
- Visual Needs: This may include recorded materials, such as a CD, or materials in You can also ask for larger print. This is provided at no cost to you. Call Member Services for more information.
- Hearing Needs: If you are deaf or hard of hearing, you can call Arizona Relay Services at 711. This telephone relay, or TTY/TDD, is a free public service. There is no cost to you. We can also get you a sign language interpreter for your medical This is provided at no cost to you. Call Member Services for more information.
- Use any hospital or other setting for emergency care.
As a BCBSAZ Health Choice Member, you have the responsibility to:
- Protect your Member ID card at all Show your ID card before you get services. Do not throw your ID card away.
- Know the name of your primary care provider (PCP). This is your assigned Tell him or her about your health history. Be sure to include any medical problems or concerns. This will help you get the best possible care.
- Follow your provider’s instructions and treatment This includes:
- Taking all of your medicines as directed by your provider
- Talking with your provider about your medical care
- Understand, participate, and agree to your treatment plan with your provider
- Use the hospital emergency room for true emergencies Go to your provider or urgent care centers for all other care.
- Make your health care appointments during office hours whenever possible. Try to see your provider for routine
- Get to your appointments on time. Call your provider ahead of time if you cannot make your Arrive at the office early if you are seeing the provider for the first time.
- If you need a ride to your appointment, call 602-386-2447 at least three (3) days before your
- Bring records of your children’s immunizations to every appointment. This includes all members who are 18 years of age or
- Call the office at least one (1) day in advance, if you cannot make your provider appointment. Remember to cancel your transportation.
- Tell AHCCCS if you have any changes to your personal information, such as address or family
- Tell BCBSAZ Health Choice or the AHCCCS Office of Inspector General (OIG) if you suspect fraud, waste, or abuse by a provider, member or other To report fraud to OIG, call 602-417-4193.
- Tell AHCCCS if you get a new health insurance plan (primary insurance) or if you cancel a health insurance plan you were covered under when you enrolled in
- Treat BCBSAZ Health Choice staff and providers with Examples of appropriate and inappropriate behaviors include:
- Appropriate behaviors:
- Arriving to your scheduled appointment as directed by the provider’s staff
- Following the recommended steps to improve your health and wellness
- Providing your provider with all of the relevant facts and not leaving out items that may impact your treatment plan i.e.: drug and alcohol use, other medications, living arrangements, etc.
- Inappropriate behaviors:
- Not treating Health Plan or Provider staff with respect and dignity
- Not showing to scheduled appointments
- Using the Emergency Department for non-life-threatening care
Members are in charge of taking care of their AHCCCS ID card. Using the card in a way that is wrong, such as loaning, selling, or giving it to someone else could result in the loss of eligibility and/or legal action as applied by Federal or State law (42 CFR 455.2). If you witness any misuse of any ID card or any other type of fraud or abuse please contact Member Services immediately at 480-968-6866.
FRAUD is any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself/herself or some other person. It includes any act that constitutes fraud under applicable Federal or State law (42 CFR 455.2).
ABUSE (of member) means provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to the DWS program; or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the DWS program (42 CFR 455.2).
What if I know of or think there may be Medicaid fraud?
Medicaid PROVIDER Fraud: If you think a Medicaid provider is involved with fraud, please contact Member Services immediately at 480-968-6866 (Maricopa County) or toll-free at 1-800-322-8670, 8 a.m. – 5 p.m., Monday-Friday (except holidays).
Medicaid CLIENT Fraud: If you think a Medicaid client is involved with fraud, please contact:
Department of Workforce Services Payment Error Prevention Unit
If you have questions or concerns about your health care, doctors, covered services, or care you are receiving please call Member Services at 1-800-322-8670.
The Member Services Department can help you with many questions like these:
- Determine financial responsibility for a drug, based on the pharmacy benefit
- Check the status on denials or appeals [Or, Initiate the exceptions process (for Medicare)]
- Order a refill for an existing, unexpired mail-order prescription
- Find the location of an in-network pharmacy [in close proximity based on zip code search
- Determine the availability of generic substitutes
For more information about your Pharmacy benefit, you may also see our Pharmacy Services page.
If you have a question about prior authorizations, Member Services can help you, call us at 1-800-322-8670 (TTY 711). Our Member Services Department is open 8 a.m. – 5 p.m., Monday-Friday (except holidays).
You can also Contact us by e-mail at HCHComments@azblue.com