Provider Forms | MCC of Arizona

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Magellan Complete Care of Arizona (MCC of AZ) appreciates your commitment and dedication to serving our Arizona Medicaid members. To make it easier for you to focus on providing great care to our MCC of AZ members, we’ve compiled our provider forms all in one place for you to access.

Click on the link to the forms you need, then download a copy and follow the instructions on the form.

AHCCCS Drug List

AHCCCS Acute and Long-Term Care Drug List

MCC of AZ Drug List

MCC of AZ Searchable Drug List

Crisis Response Network

Crisis Response Network Provider Submission Portal Announcement

Crisis Response Network

Crisis Response Network Provider Submission Portal Visual Reference Guide

Crisis Response Network

Network Management Forms

AzAHP Facility Application

AzAHP Facility Organization Data Form

AzAHP Practitoner Data Form

Utilization Management

2019 NIA Cardiac HiTech Matrix

2019 NIA IPM and Spine Surgery Matrix

Prior Authorization Code List (Revised October 15, 2020)

Inpatient Prior Authorization Request Form

Outpatient Prior Authorization Request Form

Specialty Medication Prior Authorization Request Form

ABA Prior Authorization Form

Synagis Prior Authorization Request Form

J Code Prior Authorization Changes

Effective September 1, 2020, the following medications require prior authorization:

J CODE	J CODE DESCRIPTION
J1599	INJECTION, IMMUNE GLOBULIN (IVIG)
J9042	INJECTION, BRENTUXIMAB VEDOTIN, 1MG (ADCETRIS)
J9228	INJECTION, IPILIMUMAB, 1 MG (YERVOY)
J9271	INJECTION, PEMBROLIZUMAB, 1 MG (KEYTRUDA)
J9312	INJECTION, RITUXIMAB, 10 MG (RITUXAN)
Q5116	INJECTION, TRASTUZUMAB-QYYP, 10 MG (BIOSIMILAR TO TRAZIMERA)
J9355	INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG (TRAZIMERA)
J1930	INJECTION, LANREOTIDE, 1MG (SOMATULINE)
J9043	INJECTION, CABAZITAXEL, 1MG (JEVTANA)
J3101	INJECTION, TENECTEPLASE (TNKASE)
J9305	INJECTION, PEMETREXED, 10 MG (ALIMTA)
J9039	INJECTION, BLINATUMOMAB (BLINCYTO)

Pharmacy

ADHS VFC Dose for Dose Exception Provider Form

Prescription Drug Prior Authorization

EPSDT

EPSDT Tracking Forms Cover Sheet and Instructions

EPSDT Tracking Form 3-5 Days Old

EPSDT Tracking Form 1 Month Old

EPSDT Tracking Form 2 Months Old

EPSDT Tracking Form 4 Months Old

EPSDT Tracking Form 6 Months Old

EPSDT Tracking Form 9 Months Old

EPSDT Tracking Form 12 Months Old

EPSDT Tracking Form 15 Months Old

EPSDT Tracking Form 18 Months Old

EPSDT Tracking Form 24 Months Old

EPSDT Tracking Form 3 Years Old

EPSDT Tracking Form 4 Years Old

EPSDT Tracking Form 5 Years Old

EPSDT Tracking Form 6 Years Old

EPSDT Tracking Form 7-8 Years Old

EPSDT Tracking Form 9-12 Years Old

EPSDT Tracking Form 13-17 Years Old

EPSDT Tracking Form 18-21 Years Old

Weekly Missed Provider Appointments Form

Weekly Missed Provider Appointments Form

Other

Adult System of Care - Nine Guiding Principles

Authorization to Use and Disclose (AUD) Form

Children's System of Care - Vision and Guiding Principles

General Consent Form

Hysterectomy Consent Form

Newborn Notification Fax Form

Notification of Pregnancy Form

Out-of-Home Placement for Behavioral Health Treatment Checklist

PCP Change Request Form

Provider Claim Information Form

Provider Credentialing Checklist

Provider Demographic Update Form

Provider Referral for Care Management Form

Seclusion and Restraint Reporting Form

Pregnancy Termination Form Exhibit 410-5* (Form must be submitted via email on a secure server and password protected to the MCH/EPSDT Program Manager at MCCofAZMissedAppointments@MagellanHealth.com)

Consent to Sterilize Form - 420A* ((Form must be submitted via email on a secure server and password protected to the MCH/EPSDT Program Manager at MCCofAZMissedAppointments@MagellanHealth.com)

Archived

2018 NIA Cardiac HiTech Sleep Matrix

2018 NIA IPM and Spine Surgery Matrix