At HCIC, our goal is to work closely with you and your practice team to streamline and expedite prior authorizations. Many of the items on our abbreviated prior authorization list ask for notification only. Our centralized prior authorization center is designed to streamline processes resulting in timely expedited approval of prior authorization requests.
Prior Authorization Guidelines
Requests for services that require prior authorization can be submitted on the HCIC Prior Authorization form by fax or requests can be phoned into the HCIC Prior Authorizations department. All requests must include complete diagnosis and procedure codes, and the accompanying medical documentation (as needed).
In order to expedite prior authorization and provide quality services to our members, a contracted or preferred provider is recommended for all health care services for HCIC members. Please note that all non-contracted providers must obtain authorization for any service. All out of state providers must have or be willing to obtain a valid and current AHCCCS ID number. AHCCCS-covered out of state care must be of an urgent or emergent nature.
Please refer to the HCIC Authorizations and Referrals chapter of the HCIC Providers manual and the AHCCCS Medical Policy Manual for additional summary detail of covered and excluded services.
Submitting a Prior Authorization Request
To submit a new request, obtain information about a previously submitted request or to make an urgent request call our toll-free lines:
- HCIC Medical PA Phone: 800-322-8670
- HCIC Medical PA Fax Line: 877-422-8120
- HCIC Pharmacy PA Phone: 877-923-1400
- HCIC Pharmacy PA Fax Line: 855-411-7559
Prior Authorization Resources and Forms
- HCIC Prior Authorization Grid effective until dates of services 3/31/2017
- HCIC Prior Authorization Grid effective for dates of service 4/1/2017
- HCIC Prior Authorization Grid effective for dates of service 4/4/2017
- HCIC Prior Authorization Grid effective for dates of service 10/1/2017
- HCIC Pharmacy Prior Authorization/Exception Form
- Admission to a Behavioral Health Hospital or Behavioral Health Inpateint Facility Authorization Criteria
- Continued Stay Behaivoral Health Hospital or Behavioral Health Inpatient Facility Authorization Criteria
- Admission to a Behavioral Health Hospital or Behavioral Health Inpatient Facility Authorization Criteria (Persons under 21)
- Continued Stay Behavioral Health Hospital or Behavioral Health Inpatient Facility Authorization Criteria (Persons under 21)
- HCIC Medication Prior Authorization Criteria
- ECT InterQual Criteria
- HCIC Medical Services Prior Authorization Form
- Certification of Need (CON) for Inpatient Facilities
- Re-certification of Need (RON) for Inpatient Facilities
- HCIC Prior Authorization and Continued Request Form for Behavioral Health Inpatient Facilities for Persons under Age 21
- HCIC Prior Authorization and Continued Stay Request Form for Psychiatric Acute Hospitals and Sub-Acute Facilities
- HCIC Makena Prior Authorization Form
- Additional Prior Authorization Request Forms
Notice: Effective October 8, 2015, hospital providers may begin faxing IP notifications to the following number: 480-760-4732.