Prior Authorization Guidelines & Criteria

Prior Authorization Guidelines

Attachment 1 – Detailed Outpatient Procedure Code Authorization Requirements

Change Log for Attachment 1

(Effective 04/01/2022).

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

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