Arizona Rev. Statutes-Title 20-Chapter 26-Article 1. General Provisions

See bold text below:

Section 20-3401. Definitions

In this article, unless the context otherwise requires:

1. “Adverse determination”:

(a) Means a decision by a health care services plan or its utilization review agent that the health care services furnished or proposed to be furnished to an enrollee are not medically necessary and plan coverage is therefore denied, reduced or terminated.

(b) Does not include a decision to deny, reduce or terminate services that are not covered for reasons other than medical necessity.

2. “Authorization”:

(a) Means a determination by a health care services plan or its utilization review agent that a health care service has been reviewed and, based on the information provided, satisfies the health care services plan’s requirements for medical necessity and appropriateness and that payment under the plan will be made for that health care service.

(b) Does not include any different or additional procedures, services or treatments beyond those specifically reviewed and approved by the health care services plan.

3. “Emergency ambulance services” has the same meaning prescribed in section 20-2801.

4. “Emergency services” has the same meaning prescribed in section 20-2801.

5. “Enrollee” means an individual or a dependent of that individual who is currently enrolled with and covered by a health care services plan. Enrollee includes an enrollee’s legally authorized representative.

6. “Health care service”:

(a) Means a health care procedure, treatment or service that is covered under a health care services plan.

(b) Includes providing a prescription drug, device or durable medical equipment that is covered under a health care services plan.

(c) Does not include treatments that are experimental, investigational or off label.

7. “Health care services plan”:

(a) Means a plan offered by a disability insurer, group disability insurer, blanket disability insurer, health care services organization, hospital service corporation or medical service corporation that contractually agrees to pay or make reimbursements for health care services expenses for one or more individuals residing in this state.

(b) Does not include benefits provided under limited benefit coverage as defined in section 20-1137.

8. “Medically necessary” or “medical necessity”:

(a) Means covered health care services provided by a licensed provider acting within the provider’s scope of practice in this state to prevent or treat disease, disability or other adverse conditions or their progression or to prolong life.

(b) Does not include services that are experimental or investigational or prescriptions that are prescribed off label.

9. “Medication-assisted treatment” has the same meaning prescribed in section 32-3201.01.

10. “Pharmacy benefit manager” has the meaning prescribed in section 20-3321.

11. “Prior authorization requirement”:

(a) Means a practice implemented by a health care services plan or its utilization review agent in which coverage of a health care service is dependent on an enrollee or a provider obtaining approval from the health care services plan before the service is performed, received or prescribed, as applicable.

(b) Includes preadmission review, pretreatment review, prospective review or utilization review procedures conducted by a health care services plan or its utilization review agent before providing a health care service.

(c) Does not include case management or step therapy protocols.

12. “Provider” means a physician, health care institution or other person or entity that is licensed or otherwise authorized to furnish health care services in this state.

13. “Urgent health care service” means a health care service with respect to which the application of the time periods for making a nonexpedited prior authorization decision, in the opinion of a provider with knowledge of the enrollee’s medical condition, could either:

(a) Seriously jeopardize the life or health of the enrollee or the ability of the enrollee to regain maximum function.

(b) Subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the utilization review.

14. “Utilization review agent” has the same meaning prescribed in section 20-2501.

Section 20-3402. Prior authorization; exceptions

A. A health care services plan or its utilization review agent may impose a prior authorization requirement for health care services provided to an enrollee, except for emergency ambulance services and emergency services as specified in section 20-2803, health care services arising after the initial medical screening examination and immediately necessary stabilizing treatment as specified in section 20-2803.

B. A health care services plan must allow at least one modality of medication-assisted treatment to be available without prior authorization.

Section 20-3403. Prior authorization requirements; disclosures; access

A. If a health care services plan contains a prior authorization requirement, all of the following apply:

1. The health care services plan or its utilization review agent shall make available to all providers on its website or provider portal a listing of all prior authorization requirements. The listing shall clearly identify the specific health care services, drugs or devices to which a prior authorization requirement exists, including specific information or documentation that a provider must submit in order for the prior authorization request to be considered complete.

2. The health care services plan or its utilization review agent shall allow providers to access the uniform prior authorization request forms approved by the department pursuant to section 20-3406 through the applicable electronic software system.

3. The health care services plan or its utilization review agent shall accept prior authorization requests through a secure electronic transmission.

4. The health care services plan or its utilization review agent shall provide at least two forms of access to request a prior authorization including telephone, fax or electronic means and shall have emergency after-hours procedures.

B. The health care services plan or its utilization review agent shall accept and respond to prior authorization requests for prescription benefits through a secure electronic transmission.

C. The health care services plan or its utilization review agent may enter into a contractual arrangement with a provider under which the plan agrees to process and respond to prior authorization requests that are not submitted electronically because of the financial hardship that electronic submission of prior authorization requests would create for the provider or because internet connectivity is limited or unavailable where the provider is located.

Section 20-3404. Prior authorization requirement timelines

A. If a plan offered by a health care services plan contains a prior authorization requirement, all of the following apply:

1. For prior authorization requests concerning urgent health care services, the health care services plan or its utilization review agent shall notify the provider of the prior authorization or adverse determination not later than five days after the receipt of all necessary information to support the prior authorization request.

2. For prior authorization requests concerning health care services that are not urgent health care services, the health care services plan or its utilization review agent shall notify the provider of the prior authorization or adverse determination not later than fourteen days after receipt of all necessary information to support the prior authorization request.

3. On receipt of information from the provider in support of a prior authorization request, the health care services plan or its utilization review agent shall provide a receipt in the same format that the request was made to the provider acknowledging that the information was received, unless the necessary return contact information is not provided.

B. The notification required under subsection A of this section shall state whether the prior authorization request is approved, denied or incomplete.  If the prior authorization request is denied, the health care services plan or its utilization review agent shall state the specific reason for the denial.  For a request that is considered incomplete, the provider shall have the opportunity to submit additional information.  Once the provider submits additional information on incomplete requests, the health care services plan has five days to review and respond to requests for health care services deemed urgent and fourteen days to review and respond to requests for health care services deemed not urgent.

C. A prior authorization request is deemed granted if a health care services plan or its utilization review agent fails to comply with the deadlines and notification requirements of this section.

D. A prior authorization request, once granted or deemed granted, is binding on the health care services plan, may be relied on by the enrollee and provider and may not be rescinded or modified by a health care services plan or its utilization review agent after the provider renders the authorized health care services in good faith and pursuant to the authorization unless there is evidence of fraud or misrepresentation by the provider.

E. On a denial of a prior authorization request, the enrollee and the provider may exercise the review and appeal rights specified in chapter 15, article 2 of this title.

Section 20-3405. Prior authorization of prescription drugs for chronic pain conditions

A. For a prior authorization request related to a chronic pain condition, the health care services plan or its utilization review agent shall honor a prior authorization that is granted for an approved prescription drug for the earliest of the following:

1. Six months after the date of the prior authorization approval.

2. The last day of the enrollee's coverage under the plan.

B. In relation to a prior authorization described in subsection A of this section, the health care services plan or its utilization review agent may request that the provider submit information to the health care services plan or its utilization review agent indicating that the enrollee's chronic pain condition has not changed and that the continuation of the treatment is not negatively impacting the enrollee's health. If the provider does not respond within five business days after the date on which the request was received, the health care services plan or its utilization review agent may terminate the prior authorization.

C. This section does not apply to:

1. Prescription medications if the United States food and drug administration recommends that the drug be used only for periods of less than six months.

2. Any opioid or benzodiazepine or other schedule I or II controlled substance.

D. This section does not prohibit the substitution of any drug that has received a six-month prior authorization under subsection A of this section when there is a release of a United States food and drug administration-approved comparable brand product or a generic counterpart of a brand product that is listed as therapeutically equivalent in the United States food and drug administration's publication titled approved drug products with therapeutic equivalence evaluations.

E. This section does not prohibit a health care services plan from granting a prior authorization for a duration longer than six months.

Section 20-3406. Uniform prior authorization request forms; definition

A. Notwithstanding any other law, on or before January 1, 2022, the department shall approve a uniform prior authorization request form for prescription drugs, devices or durable medical equipment and a uniform prior authorization request form for all other health care procedures, treatments and services.  On or before January 1, 2023, all providers shall use only the approved uniform prior authorization request forms and all health care services plans and utilization review agents shall accept and process prior authorization requests submitted using the approved uniform prior authorization request forms.  Prior authorization requests that are submitted on or after January 1, 2023 are invalid unless the requests are submitted on the approved uniform prior authorization request forms.  The uniform prior authorization request forms shall both:

1. Not exceed two printed pages.  This two-page limit does not apply to or include a provider's notes or documentation that the provider submits in support of a prior authorization request.

2. Meet the electronic submission and acceptance requirements prescribed in section 20-3403.

B. In approving the uniform prior authorization request forms, the department shall both:

1. Consider the following:

(a) Any existing prior authorization request forms that the centers for medicare and medicaid services or the United States department of health and human services has developed.

(b) Any national standards relating to electronic prior authorization.

(c) Any other form adopted by the director or another state agency.

2. Seek input from interested stakeholders, including providers, health care services plans, utilization review agents, pharmacists and pharmacy benefit managers.

C. This section does not prohibit a payor or any entity acting for a payor under contract with the payor from using a prior authorization methodology that uses an internet webpage, an internet webpage portal or a similar electronic, internet and web-based system if the methodology is consistent with the uniform prior authorization request forms approved by the director pursuant to this section.

D. For the purposes of this section, "provider" includes a health professional as defined in section 32-3218 or a health care institution that is licensed under title 36.

Section 20-3407. Denial of prior authorization; review of prior authorization

Before a health care insurer may issue a direct denial of a prior authorization of a service that was requested by a provider and that involves medical necessity, the medical director shall individually review the denial. During each individual review, the medical director shall exercise independent medical judgment and may not rely solely on recommendations from any other source.

See https://www.azleg.gov/arsDetail/?title=20