Arizona AZ

AHCCCS runs a SPLIT model. FFS (DFSM-administered, incl. AIHP/tribal, ALTCS-tribal, KidsCare-FFS, and Medicare crossover) has CENTRALIZED PA: a dedicated FFS Prior Authorization hub at PlansProviders/FeeForServiceHealthPlans/PriorAuthorization/ (submissionprocess / forms / requirements / criteria pages). The actual CLINICAL criteria live in the AHCCCS Medical Policy Manual (AMPM) per-service chapters - e.g. AMPM 820 (BH inpatient), 310-P (DME), 310-I (home health), 310-J (hospice), 310-R (SNF), 1120, plus BHRF documentation reqs - and PROCEDURAL PA authority is FFS Provider Manual Chapter 8. AMPM/ACOM are STATE manuals (azahcccs.gov/shared/MedicalPolicyManual + /shared/ACOM); MCOs (AHCCCS Complete Care plans, ALTCS) must follow AMPM clinical policy but each administers its OWN PA intake + its own pharmacy PBM (no unified PBM carve-out). No single state-run MCO PA portal; DIFI (ARS 20-3406) mandates uniform PA forms all plans accept since 2023-01-01 (see finding 395). WISeR pilot (vendor eviCore, live 2026-01-05, ends 2031) overlays MEDICARE-FFS prior auth only - it does NOT touch AHCCCS Complete Care members. NOTE: state_meta.primary_source_urls.pa_index (Portals/0/PriorAuthorization/PA_Requirements.pdf) is STALE/404 - live PA hub is the FeeForServiceHealthPlans/PriorAuthorization/requirements.html page.

Last award: 2018-03-05. Next due: next ACC procurement not yet announced; ALTCS-EPD re-procurement pending after YH24-0001 termination. Contracts extended through: ?.

status=partial

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

## 1. How AZ requires PA Arizona's Medicaid program, known as the Arizona Health Care Cost Containment System (AHCCCS), employs a split model for prior authorization (PA). For Fee-For-Service (FFS) programs, including AIHP (American Indian Health Program), tribal ALTCS (Arizona Long-Term Care Services), KidsCare FFS, and Medicare crossover, PA is centralized. This means that providers must submit requests through a dedicated FFS Prior Authorization hub available at PlansProviders/FeeForServiceHealthPlans/PriorAuthorization/. The documents specify detailed requirements such as service dates, diagnosis codes, billing codes, valid signatures, medical necessity documentation, and member details. Managed Care Organizations (MCOs) have delegated authority for PA within their networks. However, specific services or drugs requiring PA under MCOs are not extensively detailed in the provided documents. The AHCCCS Medical Policy Manual (AMPM) outlines criteria for various services like DME, home health, nursing facility services, hospice care, and behavioral health residential facilities. For instance, medical equipment requires an annual review by a physician or nonphysician practitioner with face-to-face encounter documentation, while nursing facility services necessitate medical necessity to avoid hospitalization. ## 2. How AZ publishes and reports PA Arizona's AHCCCS publishes its prior authorization requirements through various channels, including the AHCCCS Medical Policy Manual (AMPM) and specific policy documents for different service categories. The AMPM is a comprehensive guide that outlines criteria, documentation, and effective dates for services requiring PA. For example, the document "AMPM_310R_SNF.pdf" provides detailed medical necessity criteria for nursing facility services, specifying up to 90 days per Contract Year without carryover. The AHCCCS also maintains a centralized portal for FFS programs, where providers can submit and track prior authorization requests. This portal is accessible at PlansProviders/FeeForServiceHealthPlans/PriorAuthorization/. However, the documents do not provide specific information on how frequently or comprehensively PA data is reported publicly by the state. ## 3. AZ's CMS-0057-F and PA-reform compliance posture Arizona has made efforts to comply with the requirements of CMS-0057-F, which mandates improvements in prior authorization processes. The state's AHCCCS Medical Policy Manual (AMPM) includes detailed medical necessity guidelines for various services, such as DME, home health, nursing facility services, and hospice care. These guidelines align with CMS standards by requiring documentation of medical necessity and specifying criteria for approval. However, the documents do not provide specific information on how Arizona has addressed or plans to address all aspects of CMS-0057-F. For instance, while step therapy is mentioned in some documents (e.g., "AMPM_310DD.pdf" for covered transplants), it is not comprehensively detailed across all service categories. Additionally, the state's compliance with PA-reform initiatives, such as reducing administrative burden and improving transparency, is not explicitly outlined. ## 4. How AZ runs its own program Arizona's Medicaid program (AHCCCS) operates a split model for prior authorization, with centralized PA for FFS programs and delegated authority for MCOs. The state uses the AHCCCS Medical Policy Manual (AMPM) to outline criteria and documentation requirements for services requiring PA. For example, nursing facility services must meet medical necessity criteria to avoid hospitalization, while hospice care requires physician certification. The AHCCCS maintains a centralized portal for FFS programs, where providers can submit and track prior authorization requests. This portal is accessible at PlansProviders/FeeForServiceHealthPlans/PriorAuthorization/. The state also has specific MCOs for different populations, such as Mercy Care DCS Comprehensive Health Plan for foster-care services. The AHCCCS Medical Policy Manual (AMPM) serves as the primary source of PA requirements and criteria. For instance, "AMPM_310P_DME.pdf" outlines annual review requirements for medical equipment, while "AMPM_820_BH_Inpatient.pdf" specifies documentation needs for behavioral health residential facilities. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Centralized PA for FFS Programs:** Arizona uses a centralized portal for prior authorization in FFS programs, ensuring consistent criteria and documentation requirements. - **Detailed Medical Necessity Guidelines:** The AHCCCS Medical Policy Manual (AMPM) provides comprehensive guidelines for various services requiring PA, aligning with CMS standards. - **Delegated Authority for MCOs:** Managed Care Organizations have authority over PA within their networks, though specific service categories and criteria are not extensively detailed. ### Missing/Uncertain: - **Specific MCO PA Criteria:** The documents do not provide detailed information on which services or drugs require PA under MCOs. - **CMS-0057-F Compliance Details:** While the state has made efforts to comply with CMS-0057-F, specific actions taken and plans for addressing all aspects of the mandate are not explicitly outlined. - **PA Reporting Practices:** The frequency and comprehensiveness of PA data reporting by the state are not specified in the provided documents. - **WISeR:** Arizona IS one of the six WISeR states. WISeR = CMS "Wasteful and Inappropriate Service Reduction," a Medicare prior-authorization model live Jan 5, 2026 in AZ, NJ, OH, OK, TX, and WA. The source documents do not detail Arizona's specific WISeR implementation status, so operational details remain unverified — but Arizona's participation itself is established. - **Fiscal Agent Transition Details:** While there is a note about transitions between ACS-Inc, Conduent/Gainwell, and Xerox, specific details about these transitions are not provided. In summary, Arizona's Medicaid program has established detailed PA requirements for FFS programs through its Medical Policy Manual (AMPM) and maintains a centralized portal for submissions. However, there is a lack of comprehensive information on MCO-specific PA criteria, CMS-0057-F compliance actions, and the status of certain pilot programs like WISeR.