As a member of 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 view your Member Handbook.
Some services may have limitations and/or require a prior authorization.
What is 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)
- 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.
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 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 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.
B – UFC/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 B – UFC/ACC)
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
- Asthma Diagnosis and Management
- Atrial Fibrillation
- Attention Deficit/Hyperactivity Disorder in Children
- Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
- 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
- Hospital Acquired Infections and Antibiotic Resistance
- Immunization Guidelines and Schedules/EPSDT and Adult
- March of Dimes Premature Prevention Resources
- Mycobacterium Tuberculosis
- National Comprehensive Cancer Network (login required to access guidelines)
- Obesity in Adults
- Obsessive-Compulsive Disorder in Children and Adolescents
- 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
- Refugee Health Program
- Screening for Functional Decline in Older Adults
- Smoke-Free Arizona
- Substance Abuse Screening and Assessment Resources
- Tobacco Cessation
- US Preventative Services Task Force Guidelines