Arizona Complete Health Prior Authorization Form: Submission, Timelines, and Appeals

The Arizona Complete Health prior authorization form you need depends on which plan the member is enrolled in: Medicaid (AzCH-Complete Care Plan), Medicare (Wellcare), or Marketplace (Ambetter). Each product line has its own outpatient, inpatient, and pharmacy forms, all available as downloadable PDFs on the Pre-Auth Check page of the Arizona Complete Health provider website.¹ Using the wrong form, or sending a complete form to the wrong fax line, is the fastest way to delay a decision.

Picking the Right Form for the Member’s Plan

Start with the member’s coverage. Each product line publishes its own set:

Medicaid (AzCH-Complete Care Plan) uses an Outpatient PA Form, an Inpatient PA Form, and an Outpatient Authorization Supplemental Form when you need extra documentation space.
Medicare (Wellcare) uses separate Inpatient and Outpatient PA Forms updated January 2026, plus a Wellcare Outpatient Authorization Supplemental Form.
Marketplace (Ambetter from Arizona Complete Health) uses a DIFI Health Care Services PA Form for medical procedures and a DIFI Medication/DME/Medical Device PA Form for drug and equipment requests, with a supplemental form available.
Pharmacy requests across product lines go on the standalone Prior Authorization/Formulary Exception Request Fax Form.
Psychological and neuropsychological testing has a dedicated provider assistance tool that walks through the documentation requirements.

If you aren’t sure whether a given service even requires authorization, each product line has its own online Pre-Auth Check Tool on the same page.¹ Run the code through the correct tool before you fill anything in.

What You Have to Put on the Form

The core data fields are the same across product lines. The outpatient form states plainly that incomplete forms will be rejected, so treat every required field as a hard stop.²

Member ID: the Medicaid, Medicare, or Marketplace identification number, printed one digit per box.
Provider NPIs: both the requesting provider’s and the servicing provider’s National Provider Identifier numbers.
Diagnosis code: the ICD-10 code for the member’s condition.
Procedure codes: the primary CPT or HCPCS code with any applicable modifier, plus fields for additional procedure codes if more than one service is being requested.

The pharmacy PA form adds fields specific to drug requests: medication name, strength, dosage, quantity, and a list of medications previously tried along with dates of use.³

Clinical Documentation to Attach

Both the medical and pharmacy forms require clinical documentation with the submission. The outpatient form warns that missing clinical information may delay the determination.² Plan to include:

Recent chart notes showing the clinical basis for the requested service.
Lab results if applicable to the diagnosis or treatment.
Height and weight, specifically called out on the pharmacy form for dosage-dependent medications.
For pharmacy requests, a treatment history listing each medication previously tried, approximate dates of use, and the reason it was discontinued or failed.
A written medical justification explaining why the requested service is necessary for the member’s condition.

How to Submit the Request

Arizona Complete Health accepts prior authorization requests through its online provider portal, by fax, or by phone. The portal is the fastest route; requests feed directly into the plan’s system and receive a quicker response than paper submissions.¹

Provider Portal

Log in or register at the Arizona Complete Health website under the provider login page. The portal handles both Medicaid and Marketplace prior authorization requests online and gives real-time tracking once a request is submitted. If you have not registered, set up credentials through the provider section first.

Fax

Medical and pharmacy requests go to different fax numbers:

Fax numbers for medical (non-pharmacy) inpatient and outpatient requests are printed on the PA forms themselves. Double-check the number on the version of the form you are submitting, because routing a pharmacy request to the medical fax line, or vice versa, will cause processing delays.

Phone

To check the status of a submitted prior authorization, call (866) 399-0928.³

How Long the Decision Takes

Federal Medicaid managed care rules set the outer limits. For plan years beginning on or after January 1, 2026, the standard authorization decision must be made within 7 calendar days of receipt, down from the previous 14-day window. The plan may extend that by up to 14 additional calendar days if the member or provider requests the extension, or if the plan needs more information and can show the delay benefits the member.⁵

Urgent requests, where following the standard timeline could seriously jeopardize the member’s life, health, or ability to recover, qualify for an expedited decision within 72 hours of receipt. The same 14-day extension rules apply if the extension serves the member’s interest.⁵ Both the provider and the member receive notification, and denials come with a written explanation of the reasons and instructions for next steps.

When You Don’t Need a Form

Emergent and post-stabilization services do not require prior authorization under any Arizona Complete Health product line.⁶ If a member arrives at an emergency department, the treating facility should deliver necessary care without waiting for plan approval. Services that follow the emergency, such as an inpatient admission after the member is stabilized, are handled separately on a concurrent or retrospective basis.

If the Request Is Denied

A denial is not final. Arizona Complete Health offers a structured sequence of options starting with a clinical conversation and escalating to a formal appeal.

Peer-to-Peer Review

You can request a discussion with the plan’s medical director who issued the denial. This is a chance to present additional clinical context; it does not replace the formal appeal process, and the medical director cannot overturn a denial through the peer-to-peer call once a Notice of Adverse Benefit Determination has been issued.⁷ The deadlines are tight:

Inpatient denials: within 2 business days of the denial notice or discharge date, whichever is later. In extenuating circumstances, the plan may allow up to 10 business days.
Outpatient denials and planned admissions: within 30 calendar days of the denial determination letter.

For a physical health peer-to-peer, call 888-788-4408 (press 3 for Provider, 7 for Authorization, 1 for Peer-to-Peer). For behavioral health, call 520-809-6657 and leave a message, or email AzCHPeertoPeer@azcompletehealth.com for either type.⁷ Once the plan receives your request, it has two business days to reach out and schedule the call. If you do not return the outreach promptly, the denial stands.

Formal Appeal

If the peer-to-peer does not resolve the issue, you can submit a formal appeal on the member’s behalf. A signed and dated Authorization of Representation from the member must accompany provider-filed appeals. Standard appeals are resolved within 30 days of receipt, with a possible 14-day extension if more information is needed. Expedited appeals, for situations where the standard timeline could seriously harm the member, are resolved within 72 hours.⁸ Members already receiving the service that was denied on continuation may be able to keep receiving it during the appeal; ask the Grievance and Appeals Department about continuing services when you file, and be aware that if the appeal ultimately fails, the member may owe for services received in the interim.⁹

Who Pays When Authorization Is Missing

When a service is delivered without the required prior authorization, the financial fallout depends on how the claim is coded at denial. If the insurer assigns a Contractual Obligation denial code, the provider absorbs the cost and cannot bill the member for the balance. If the denial carries a Patient Responsibility code, meaning the member’s plan placed the burden of obtaining authorization on the patient, the provider can bill the member directly. For providers, the takeaway is to get the authorization before the service. For members, confirm with your provider’s office that authorization has been approved, not just requested, before your procedure date.

1
Arizona Complete Health. Pre-Auth Check
2
Arizona Complete Health. Arizona Complete Health Prior Authorization Form
3
Arizona Complete Health. Arizona Complete Health Prior Authorization Form
4
Arizona Complete Health. Changes in Pharmacy Fax and Portal Use Reminder
5
eCFR. 42 CFR 438.210 – Coverage and Authorization of Services
6
Arizona Complete Health. Arizona Complete Health Prior Authorization
7
Arizona Complete Health. Medical Management/Utilization Management Requirements
8
Arizona Complete Health. Grievance and Appeal System
9
AHCCCS. How to File an Appeal of a Health Care Coverage Decision