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Prior Authorization
Certain medical services require authorization from Capstone Health Plan prior to services being rendered. Please refer to Services that Require Prior Authorization.
How to Complete a Prior Authorization Request
Providers are requested to submit a Prior Authorization Request Form for all authorization requests. There is only one form for all requests. Pertinent medical documentation in support of the request must be attached or the request may be denied.
Documentation must include the following:
- Patient name, DOB, AHCCCS number
- Requesting provider name, phone and fax number, contact person
- Name of specialist or facility to which the patient is being referred
- Phone number and fax number for referred specialist or facility Diagnosis (ICD-9 code)
- Description of requested service (CPT or HCPCS codes)
- Documentation of medical necessity for the service e.g., last visit notes, therapist notes etc.
Deadlines for Requesting Authorization
It is Capstone Health Plans policy that all requests for authorization must be made PRIOR to the service being rendered. Capstone does not provide retro authorizations.
Authorizations are processed in the order in which they are received, unless delays in getting services could potentially cause the member grievous harm, in which case Capstone expedites the request. Per AHCCCS rules Capstone has up to 14 days to respond to a request for prior authorizations. Please do not send your requests at the last minute or they will not be processed in time and result in claim denial.
Emergency services, such as ER visits or hospital admissions, must be reported to Capstone Health Plan within 72 hours of admission. Emergency transportation providers must notify Capstone within ten (10) business days from the date of service. Failure to notify Capstone within the specified time frames may result in claim denial.
