Prior Authorizations

Prior Authorizations

Medical Services

Some medical services and specialists need prior approval by BUFC/ACC. If they do, your primary care provider (PCP) must arrange for prior authorization for these services. BUFC/ACC must review these requests. Your PCP's office will let you know if your prior authorization request is approved. You can also call our Customer Care Center to find out the status.

If your PCP's request is denied, BUFC/ACC will let you know by mail. If you have a question about the denial, you may call our Customer Care Center. You can also write to us at the address listed below. Please review your Member Handbook for more information about filing an appeal for a denied authorization. The appeal decision sent by BUFC/ACC will also tell you how to request a State Fair Hearing.

If you need services not covered by BUFC/ACC, due to moral or religious obligations, please contact our Customer Care Center for help.

Behavioral Health Services

If you feel that you need help with an emotional, alcohol or drug problem, you do not need a referral. For non-emergency help, you may call the following people:

  • Your PCP
  • BUFC/ACC Customer Care Center at (800) 582-8686
  • BUFC/ACC Behavioral Health Care Manager of the day during business hours

Covered Services

You do not need a referral from your PCP for the following services:

  • Emergency Services
  • Behavioral Health issues
  • OB/GYN services
  • Dental services

The care listed below will be covered through BUFC/ACC. Some services may have limitations and/or require a prior authorization, contact our Customer Care Center for more information:

  • Ambulance for emergency care
  • Behavioral Health Care
  • Care while you are pregnant
  • Care Management
  • Checkups for children, pregnant women, Qualified Medicare Beneficiary (QMB), and Seriously Mentally Ill (SMI) members
  • Children's services including routine dental care
  • Chiropractic services for children and QMB
  • Emergency medical and surgical services related to dental (oral) care
  • Disease Management
  • Dialysis
  • Emergency Dental
  • Emergency or Urgent Care medical treatment
  • Eyeglasses or contacts for children, or adults only after cataracts are removed;
  • Family planning / birth control
  • Health care services through screenings, diagnosis and medically necessary treatments for members 21 years of age or older
  • Hospice care
  • Hospital care
  • Lab work and x-rays
  • Medical tests
  • Medically needed foot care performed by a licensed podiatrist; a podiatrist may provide foot care for members when ordered by a PCP or other provider
  • Medicine from the approved drug list, the BUFC/ACC Drug Formulary
  • Organ transplants
  • Orthotics
  • PCP office visits
  • Preventative and routine gynecological services for female members (no referral needed)
  • Transportation to health care visits
  • Speech, Physical and Occupational Therapies
  • Second opinions: You have the right to have a second opinion from a qualified health care professional within the network. If one is not available in the network, you have the right to request a second opinion outside the network at no cost to you
  • Supplies and equipment, including BUFC/ACC Drug Formulary diabetic testing equipment and supplies
  • Well-child checkups including dental, hearing, shots and vision care

Your PCP may want you to see a specialist or get special services. He/she will arrange for the special care listed below. Some of these may require prior authorization from BUFC/ACC:

  • Diet and health teaching
  • Home health care
  • Organ transplants
  • Skilled nursing home care
  • Rehabilitation services like physical and occupational therapy, or speech therapy (for members 20 years and younger)
  • Specialist care
  • Social Services

Medical Necessity, Criteria and Standards of Care

BUFC/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)
  • National Clinical Guidelines
  • Medical Policies
  • 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.

BUFC/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. BUFC/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 BUFC/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

BUFC/ACC Clinical 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 BUFC/ACC members
  • Adopted in consultation with BUFC/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

BUFC/ACC clinical practice guidelines are recommendations to support clinical 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 in unique clinical situations and should be clearly substantiated in the medical record.

BUFC/ACC clinical practice guidelines are endorsed or 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.

Additional guideline resources are available through the National Guideline Clearinghouse.

Clinical Practice Guidelines (Endorsed by BUFC/ACC)

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