Prior Authorization Guidelines & Criteria

Prior Authorization Guidelines & Criteria

Prior Authorization Guidelines
Attachment 1 – Detailed Outpatient Procedure Code Authorization Requirements
Change Log for Attachment 1
(Effective 06/01/2022).

Prior Authorization Criteria

Care1st uses clinically sound, nationally developed and accepted criteria for making medical necessity decisions. Clinical criteria utilized in decision making include, but is not limited to:

  • AHCCCS Guidelines/ DDD Criteria
  • MCG Guidelines
  • American College of Obstetrics and Gynecology
  • The American Academy of Pediatrics
  • WellCare Clinical Care Guidelines (CCG’s)
  • CMS Guidelines
  • ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 3rd edition

Note: There is no prior authorization for Behavioral Health Crisis Services

Disease Management Guidelines | Practice Guidelines and Preventive Health Guidelines