Prior Authorization & Clinical Guidelines

At BCBSAZ Health Choice Pathway HMO D-SNP, our goal is to work closely with providers to streamline and expedite prior authorization requests for our members.
  • Referrals

    A referral is a written order from your primary care provider (PCP). In some situations, our plan or your PCP must give you a referral for you to get certain medical services from another provider in our plan.

    You can get the services listed below without getting a referral from your PCP.

    • Emergency care or urgently needed services
    • Flu shots, COVID-19 vaccinations, Hepatitis B vaccinations, and pneumonia vaccinations
    • Routine women’s health care includes breast exams, screening mammograms (x-rays of the breast), Pap tests, and pelvic exams as long as you get them from an in-network provider.
    • In-network Specialist provider office visits do not require a referral, except for pain management services.

    You can also get other kinds of care without a referral from your PCP (see Section 2.2 of Chapter 3 in your Evidence of Coverage).

    Prior Authorizations

    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 BCBSAZ Health Choice Pathway will cover the cost of the service.

    A PA request is a form your provider fills out and sends to BCBSAZ Health Choice Pathway. 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 referrals and prior authorizations, Member Services can help you. Call us at 1-800-656-8991 (TTY 711). Our Member Services department is open 8 a.m. to 8 p.m., 7 days a week. You can also contact us by e-mail at HCHComments@azblue.com.

Prior Authorization Guidelines

Clinical Guidelines

  • NCQA-white-bcbsaz

  • NCQA-HEDIS-bcbsaz

© BCBSAZ Health Choice Pathway

BCBSAZ Health Choice Pathway (HMO D-SNP) is a Health Plan with a Medicare contract and a contract with the state Medicaid program. Enrollment in BCBSAZ Health Choice Pathway (HMO D-SNP) depends on contract renewal. BCBSAZ Health Choice Pathway is a subsidiary of Blue Cross® Blue Shield® of Arizona.

Member Services can be reached at 1-800-656-8991, TTY 711, 8 a.m. to 8 p.m., 7 days a week. Member Services also has free language interpreter services available for non-English speakers.

Every year, Medicare evaluates plans based on a 5-star rating system.

H5587_D40881PY25_M Last Updated: 10/1/24