We’re now accepting prior authorization requests via the Availity Essentials™ portal. The integrated workflow makes it quick and easy to:
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Enter your service information
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Validate the member’s current eligibility
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See if authorization is required (according to the member’s specific benefit plan)
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Upload attachments
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Check the status of your request via the dashboard
Be sure to invite your staff to take advantage of this newly implemented feature. If you have questions, feel free to reach out to the Availity Client Service team at 800-282-4548.
New updates effective August 1
Site-of-service review required for minor procedures performed in outpatient hospital settings
Effective August 1, 2026, a preservice site-of-service review will be required for certain types of minor elective services (i.e., colonoscopies, EGDs, knee and shoulder arthroscopies, lithotripsies, and hernia repairs) when scheduled to be performed in hospital outpatient facilities. In this setting, the services will be considered medically necessary only if the patient’s age or health condition meets certain criteria for a higher level of care. If not, the services must be performed in an ambulatory surgery center. The site-of-service review process will also consider any logistical and access challenges related to the member’s location and circumstances.
The new policy applies only to our commercial plans. It does not apply to Federal Employee Program®(FEP®) plans or Medicare Advantage plans. For details, please preview a draft of the new Site of Service for Outpatient Procedures medical policy (includes a list of the applicable procedure codes). Applicable codes and messaging will also be added to the prior auth requirements code list, lookup tool, and Availity prior auth workflow.
Outpatient observation service
Effective August 1, 2026, observation service code G0378 will only be eligible for reimbursement when the observation period meets or exceeds eight hours. Observation for less than eight hours is included in the payment for services including but not limited to emergency room visits and critical care. See the updated Included Services Pricing Guidelines.
Please report hourly observation services with HCPCS code G0378 (hospital observation service, per hour) under revenue code 0762. When medically necessary and documented, a maximum of 72 hours of outpatient observation services are payable.
Note: This update applies to members with AZ Blue commercial, FEP, and BlueCard® (out-of-area) plans. Medicare Advantage plans follow specific CMS pricing and payment rules.
Reminders about what starts July 1
Standard prior authorization penalty policy change
Partnering with providers through the prior authorization process helps ensure the best clinical outcomes for our members. We’re committed to making the request process easy and efficient for you. To further strengthen prior authorization compliance, we are also updating our standard penalty policy for most AZ Blue commercial plans. For dates of service on and after July 1, when a required prior auth is not obtained, the claim (or claim line) for that service will be denied. Billing the member for the service is not permitted. Get the details.
Expansion of our jointly administered plans
This line of business allows large, self-funded groups to manage their benefit plan through AZ Blue and a third-party administrator (TPA). Starting July 1, seven groups will be switching from their current plan to a jointly administered plan. Medical policy and prior authorization for these groups will be administered by AmeriBen or American Health Group. See a list of prefixes and UM information for these groups.
Prefix list update
We have updated the prefix list to include the new prefixes for groups with jointly administered plans. Preview the updated list. For more information about prefixes and prefix replacements, visit azblue.com/prefix.
In addition to the annual fee schedule updates (see below), we want to let you know about some changes for billing behavior identification assessments. Effective July 1, we have added new pricing actions for modifiers HN, HO, and HP when appended to CPT codes 97151 through 97158. The HM modifier will continue to pay at 100% of the fee. For specific information, see the updated Modifier Pricing Actions list.
Part B step therapy
As new biosimilars and medications are approved by the FDA, we review our Part B step therapy policy for potential updates. Please see our revised policy, effective July 1.
Use this new diagnosis code for Type 2 diabetes in remission: E11.A
Please use the E11.A diagnosis code to let us know when a patient is considered to be in remission, according to these three CMS criteria:
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No current diabetic complications
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No longer on any diabetic medications, including GLP-1 agonists for treatment of diabetes
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HbA1c level has been ≤ 6.5 for at least three months after stopping diabetic medications
Note: Patients in remission status must still be included in your reporting for the HEDIS® diabetes measures. Past damage, silent complications, and reversibility remain serious risks for patients in remission. That’s why ongoing monitoring and reporting of diabetes-related care is essential. This includes A1c labs, blood pressure screenings, eye exams, and kidney testing.
We’re now using MCG 30th edition
For service dates on and after June 16, we’re now using the 30th edition of the MCG care guidelines. To access the guidelines, visit Availity Essentials > Payer Spaces > AZ Blue > Prior Authorization and Medical Policies > AZ Blue Plans > Medical Policies.
These prior authorization updates started June 1
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Varicose vein treatments require prior authorization for all commercial plans. See the codes.
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These five injectable drug codes require prior auth for all commercial plans (not just plans delegated for EviCore): J0585 through J0589
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One code is no longer eligible for the Gold Card Program: 22840 (posterior non-segmental instrumentation)
30-day readmission policy update
Claims for acute care hospital readmissions that occur within 30 days after discharge are reviewed in relation to the initial hospitalization to evaluate the circumstances. As of June 1, if the readmission is determined to be a continuation of care, and the claim is for the same DRG as the original claim, the claim for the readmission will be denied as included in the primary admission. If the claim is for a similar DRG, it will go through further review by a clinician.
Non-reimbursable modifiers: Certain modifiers indicate that an external funding source holds financial responsibility (i.e., HU, HV, HW, HX, HZ, QJ, SE, SL). AZ Blue will not reimburse for these. See the revised Modifier Pricing Actions List.
Helpful tips
Don’t forget the barcode! When responding to a records request for a claim, be sure to send a copy of the barcoded request letter we sent you. We need that barcode in order to match your records to the correct claim. Sending records without the barcode letter can lead to unnecessary delays and claim denials.
Records tip for appeals: For quicker turnaround times, please place your grievance form or appeal request cover sheet at the beginning of your submission and send only the documentation that pertains to your appeal (rather than the entire patient record). This will help us quickly identify what you’ve sent as an appeal, so it can be directed to the correct team for review.
Reporting tip for HEDIS CBP measure: When an initial blood pressure reading is ≥139/89, we recommend a second reading (later in the same visit) when the patient is more relaxed. This often results in lower and truer numbers. Please capture and report all readings in the patient record. This simple best practice often prevents a HEDIS care gap that would require further attention.
AZ Blue Medicare Advantage plans do cover annual exams: Please note that although our 2026 EOC does not mention annual exams, they are definitely a covered benefit for our Medicare Advantage plans. Go ahead and schedule the exams, and bill us accordingly!
Learning opportunities
Perinatal mental health: Designed to support maternal mental health in Arizona, this free, self-paced training takes you through three one-hour modules to help you deliver compassionate, effective care to this vulnerable population. See course and CE information.
Availity is a separate, independent company contracted with AZ Blue for provider portal services. Availity is a registered service mark and Availity Essentials is a service mark of Availity, LLC.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
The MCG care guidelines are the proprietary and copyright-protected information of MCG Health, part of the Hearst Health network.
Blue Cross, Blue Shield, the Cross and Shield Symbols, Federal Employee Program, FEP, and BlueCard are registered service marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
