Fee-for-Service Medicaid Prior Authorization Criteria

This page provides Fee-For-Services (FFS) Medicaid and Childrens Special Health Care Services criteria and documentation requirements for submission of Prior Authorization (PA) requests when PA is required for selected physician-administered drugs, surgeries, procedures, services, medical supplies and equipment. Criteria will be updated, and new criteria added as they become available.

For the most current requirements, please refer to this page rather than downloading each criteria page.

All PA requests should be submitted electronically, via CHAMPS. For questions regarding FFS Prior Authorization, call the Program Review Division at 800-622-0276. If CHAMPS is inaccessible, requests may be faxed to 517-335-0075.