Prior Authorizations

As a member of Banner – University Family Care/ACC (B – UFC/ACC), your health plan provides covered health care benefits and services. Your benefits include behavioral health services and some dental. 

Your provider may provide these services, or they may make plans for you to get these services from another provider (sometimes called a specialist) by creating a referral. Some covered services require that your doctor or provider obtain a prior authorization.

  • For a list of covered services and more information on prior authorizations, please review your Member Handbook.

What is a Prior Authorization?

Prior Authorization is a process where your provider obtains approval for the service from B – UFC/ACC. We must approve services that require prior authorization before the services are given to you.

B – UFC/ACC must review these authorization requests before you can get the service. Your provider office will let you know when authorization is obtained. You can also contact our Customer Care Center to find out the status of the request.

B – UFC/ACC will let you know by mail if prior authorization is denied. In the letter, you will have instructions on how to file an appeal. The letter will also describe the reason for the denial. If you have a question about the denial and need help, please call our Customer Care Center, or write to B – UFC/ACC.

If additional support is needed to better understand the process and your rights, contact a member advocate by email at oifateam@bannerhealth.com.

Covered Services that Require Prior Authorization

Services that require prior authorization include:

  • Some Behavioral Health Services
    • Out of Network
    • Inpatient Facility
    • Behavioral Health Residential Facility
    • Psychological and Neuropsychological Testing
    • Electroconvulsive Therapy (ECT)
  • Inpatient hospital services
    • Planned, non-emergency admissions
    • Non-emergency Out of Network admissions
    • Surgeries, pre-scheduled
  • Some medical equipment and supplies
    • DME/electric equipment
    • Prosthetics and orthotics
  • Special lab work
    • Genetics
  • Some scans and Imaging
    • MRI, MRA
    • PET Scans
  • Some Medications
  • Dialysis
  • Some Outpatient procedures and surgeries
    • Some cosmetic procedures
  • Non-emergency out of network services and treatments

If you have any questions about these services or if you would like to discuss options to address your needs, please call our Customer Care Center at (800) 582-8686, TTY 711, so we can discuss your options. Contact your PCP to check if a service or medication needs a prior authorization. 

Please review your Member Handbook for services requiring prior approval. 

Criteria that decisions are based on are available upon request. You may also view the related sections below.

Important Information Related to RSV and Synagis

B – UFC/ACC is pausing prior authorization requirements this season for Synagis® (palivizumab). Effective November 15, 2022, prior authorization for Syangis is not required. This is effective for the remainder of the 2022-23 RSV season.

Medical Necessity, Criteria and Standards of Care

B – UFC/ACC and our providers use information to help us when reviewing a prior authorization. The standards we use in clinical decision-making includes:

  • AHCCCS (Medicaid Guidelines)
  • MCG Care Guidelines
  • Medical Policies
  • Clinical Practice Guidelines
  • Member’s health history

The standards used helps us when making decisions for improved quality of care to our members. Our providers are expected to partner with our members to meet their specific needs.

B – UFC/ACC has a clinical review team to ensure our members receive medically necessary services. The review team uses a member’s treatment plan and our clinical standards to make a final decision. B – UFC/ACC does not reward employees and providers to decrease our member’s care or services needed.

If our review team denies a service authorization request, a B – UFC/ACC Medical Director will review the request. A member may also request the clinical criteria used when making any kind of decision related to medical necessity. Members may call our Customer Care Center for further assistance. Please see our section on “Clinical Practice Guidelines.” Our Clinical Practice Guidelines are recommendations to support clinical decision-making.

Clinical Practice Guidelines

B – UFC/ACC Clinical Practice Guidelines are:

  • Based on valid and reliable clinical evidence or a consensus of health care professionals in that field
  • Selected with consideration of the needs of B – UFC/ACC members
  • Adopted in consultation with B – UFC/ACC providers
  • Based on National Practice Standards and
  • Developed by health care professionals and based on a review of peer‐reviewed articles published in the United States when national practice guidelines are not available.

B – UFC/ACC clinical practice guidelines are used to support clinical decision‐making. They should not be used as the sole source of information or guidance when making clinical decisions but serve as a guide to informed decision making.

Primary care physicians, specialists, and other health care providers are expected to collaborate with their patient and/or the patient's surrogate to develop and implement treatment plans that are individualized to meet the specific needs of each patient. This collaboration allows deviation from the guideline when appropriate and should be clearly documented in the medical record.

Clinical practice guidelines are developed with designated, desired outcomes and associated, standardized measures of effectiveness. These guidelines are disseminated to all affected providers and are available to all providers, members, potential members, and affiliated allied health professionals upon request.