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 email@example.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
- Some scans and Imaging
- MRI, MRA
- PET Scans
- Some Medications
- 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.
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.
Note: By clicking on any of the links below, you will be leaving our website.
- AIDS / HIV Information
- Antithrombotic Therapy and Prevention of Thrombosis
- Arizona Department of Health Services, Division of Behavioral Health Services - Click on “Clinical Guidance Tools”
- State Suicide Prevention Plan
- Child and Family Team
- Family and Youth Involvement in the Children’s Behavioral Health System
- Psychiatric Best Practices for Children: Birth to Five Years of Age
- Support and Rehabilitation Services for Children, Adolescents and Young Adults
- Transition to Adulthood
- The Unique Behavioral Health Service needs of Children, Youth and Families Involved with CPS
- Working with the Birth to Five Population
- Arizona Opioid Prescribing Guidelines
- Asthma Care Quick Reference
- Atrial Fibrillation
- Attention Deficit/Hyperactivity Disorder in Children
- Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
- Cancer Network (login required to access guidelines)
- Choosing Wisely Campaign
- Congestive Heart Failure
- Diagnosis and Treatment of Depression in Adults
- Eating Disorders in Children and Adolescents
- Elder Abuse and Neglect Screening and Resources
- Falls in Older adults
- Gay, Lesbian and Bisexual Sexual Orientation, Gender Nonconformity and Gender Discordance in Children and Adolescents
- Guidelines for Management of Sepsis and Septic Shock
- Heart Failure
- Hospital Acquired Infections and Antibiotic Resistance
- Immunization Guidelines and Schedules/EPSDT and Adult
- March of Dimes Premature Prevention Resources
- Mycobacterium Tuberculosis
- Myocardial Infarction, Management of Patients with ST‐Elevation
- Non-ST Elevation Acute Coronary Syndromes
- Obesity in Adults
- Older Adults-National Council on Aging
- Otitis Media Guidelines
- Patient‐Centered Care for Older Adults with Multiple Chronic Conditions (login required to access guidelines)
- Pediatric Overweight and Obesity, Prevention and Reduction
- Pediatric Preventive Health Care Guidelines
- Preparing for Public Health Threats and Emergencies in Arizona
- Preventative Pediatric Health Care
- Preventive Services Recommendations for Adults
- Refugee Health Program
- Screening for Functional Decline in Older Adults
- Smoke-Free Arizona
- ST-Elevation Myocardial Infarction
- Substance Abuse Screening and Assessment Resources
- Tobacco Cessation
- US Preventative Services Task Force
Banner – University Family Care provides all criteria used to support clinical decision‐making above in Clinical Practice Guidelines.
If you would like a copy of the criteria used in medical necessity decision making, please call our Customer Care Center.
Banner – University Family Care affirms the following:
- Utilization Management decision making is based only on appropriateness of care and service and existence of coverage.
- The organization does not specifically reward practitioners, providers, or other individuals for issuing denials of coverage.
- Financial incentives for Utilization Management decision-makers do not encourage decisions that result in underutilization.