R9-28-201. General Requirements

In addition to the exclusions and limitations specified in this Article, services provided to a member are covered services if: 1. Medically necessary, cost effective, and federally reimbursable; 2. Coordinated by a case manager in accordance with requirements specified in R9-28-510; 3. The provider obtains prior authorization as required by a member’s program contractor or by the Administration: a. Failure of the provider to obtain prior authorization is cause for denial. b. Services provided during prior period coverage are exempt from prior authorization requirements; 4. Provided in facilities or areas of facilities that are licensed or certified under Article 5 of this Chapter, or meet other requirements described in Article 5 of this Chapter; 5. Rendered by AHCCCS registered providers as permitted under this Chapter and within their scope of practice; and 6. Provided at an appropriate level of care, as determined by the case manager or the primary care provider.