Some medical services and specialists need prior approval by BUFC/ALTCS. If they do, your primary care provider (PCP) must arrange for prior authorization for these services. BUFC/ALTCS 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/ALTCS 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/ALTCS will also tell you how to request a State Fair Hearing.
If you need services not covered by BUFC/ALTCS, due to moral or religious obligations, please contact our Customer Care Center for help.
You do not need a referral from your PCP for the following services:
- Emergency care
- Behavioral Health issues
- OB/GYN services
- Dental services
The care listed below will be covered through BUFC/ALTCS. Some services may have limitations and/or require a prior authorization, contact your Case Manager or the Customer Care Center for more information:
- Ambulance for emergency care
- Behavioral Health Care
- Pregnancy care
- Case management
- Checkups for children, pregnant women, QMB, and SMI members
- Children's services including routine dental care
- Chiropractic services for children and QMB
- Diet and health teaching
- Disease Management
- Durable Medical Equipment (DME)
- 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 needed treatments for members 21 years of age or older
- Hospice care
- Home and Community Base Services (HCBS) and Assisted Living Facilities (ALF)
- Hospital care
- Lab work and x-rays
- Limited dental services (members over the age of 20)
- Medical tests
- Medically needed foot care done by a licensed Podiatrist. A Podiatrist may provide foot care for members when ordered by a PCP.
- Medicine from the approved drug list, the BUFC/ALTCS Drug Formulary
- Organ transplants
- PCP office visits
- Preventative and routine gynecological services for female members (no referral needed)
- Private Nursing Care
- 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 ask for a second opinion outside the network at no cost to you
- Skilled nursing home care
- Supplies and equipment, including BUFC/ALTCS Drug Formulary diabetic testing equipment and supplies
- Well-child checkups including dental, hearing, shots and vision care
Medical Necessity, Criteria and Standards of Care
BUFC/ALTCS 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/ALTCS 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/ALTCS 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/ALTCS 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
Banner – University Family Care/ALTCS 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/ALTCS members
- Adopted in consultation with BUFC/ALTCS 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/ALTCS 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/ALTCS 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.
Clinical practice guidelines may include treatment that requires prior authorization and/or is not covered by a member’s BUFC/ALTCS benefit structure. Additional guideline resources are available through the National Guideline Clearinghouse.
BUFC/ALTCS Practice Guidelines are reviewed by the BUFC/ALTCS Quality Management / Performance Improvement (QM/PI) Committee at least annually to determine if the guidelines remain applicable, represent best practice standards, and reflect the current medical standards. The guidelines noted above were last reviewed and approved in November 2016. The BUFC/ALTCS Chief Medical Officer, Medical Directors and other applicable clinical resources are available to providers that request and/or require additional information related to BUFC/ALTCS Clinical Practice Guidelines.
Clinical Practice Guidelines (Endorsed by BUFC/ALTCS)
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