As a member of Banner – University Family Care/ACC (B – UFC/ACC), you can receive health care benefits and services that are covered (including dental and behavioral health). For a list of covered services, please review your Member Handbook.
Some services may have limitations and/or require a prior authorization. Prior Authorization means your provider has requested permission for you to get a special service. B – UFC/ACC must approve these requests before the delivery of services. Prior authorization is approved based on a review of medical need.
Some health care services and treatments may need prior authorization by B – UFC/ACC. Your provider must request prior authorization for these services. B – UFC/ACC must review these authorization requests before you can get the service. Your PCP’s office will let you know when authorization is obtained.
You can call our Customer Care Center to find out the status of the request as well as contact a member advocate at firstname.lastname@example.org if additional support is needed to better understand the process and your rights. 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.
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.
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