Prior AuthorizationsSome medical services and specialists need prior approval by Banner – University Family Care/ALTCS (B – UFC/ALTCS). If they do, your primary care provider (PCP) must arrange for prior authorization for these services.
What is a Prior Authorization?
Prior Authorization is a process where your provider obtains approval for the service from B – UFC/ALTCS. We must approve services that require prior authorization before the services are given to you.
B – UFC/ALTCS must review requests for prior authorizations. 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, B – UFC/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 B – UFC/ALTCS will also tell you how to request a State Fair Hearing.
If you need services not covered by B – UFC/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 B – UFC/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 B – UFC/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 B – UFC/ALTCS Drug Formulary diabetic testing equipment and supplies
- Well-child checkups including dental, hearing, shots and vision care
Important Information Related to RSV and Synagis
B – UFC/ALTCS is pausing prior authorization requirements this season for Synagis® (palivizumab). Effective November 15, 2022, prior authorization for Syangis is not required. This is effective for the remainder of the 2022-23 RSV season.
Medical Necessity, Criteria and Standards of Care
B – UFC/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)
- 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/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. B – UFC/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 B – UFC/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 – UFC/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 B – UFC/ALTCS members
- Adopted in consultation with B – UFC/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
B – UFC/ALTCS 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.
Clinical practice guidelines are reviewed by the B – UFC/ALTCS Quality Management / Performance Improvement (QM/PI) Committee annually to determine if the guidelines remain applicable, represent best practice standards, and reflect the current medical standards. The B – UFC/ALTCS Chief Medical Officer, Medical Directors and other applicable clinical resources are available to providers that request and/or require additional information related to clinical practice guidelines.
Note: By clicking on any of the links below, you will be leaving our website.
- AIDS / HIV Information
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- AHCCCS Behavioral Health System Practice Tools: AMPM 200
- Arizona Opioid Prescribing Guidelines
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- Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
- Cancer Network (login required to access guidelines)
- Choosing Wisely Campaign
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- Elder Abuse and Neglect Screening and Resources
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- 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
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- Older Adults-National Council on Aging
- Otitis Media Guidelines
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- Pediatric Overweight and Obesity, Prevention and Reduction
- Pediatric Preventive Health Care Guidelines
- Preparing for Public Health Threats and Emergencies in Arizona
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- 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.
Behavioral Health Guideline are:
- Population Outcome Based
- Research-Based Knowledge
- Redefined Through Quality Improvement
- Compatible with System Policies and Resources
Primary care physicians, specialists and other health care providers are expected to use best practice guidelines in a way that promotes the achievement of desired member outcomes. Best practice guidelines provide research-based knowledge that is intended to work in collaboration with clinical guidelines and service delivery. Best practice guidelines enhance service delivery by ensuring member focused treatment while helping to bridge evidence-based clinical practice research with individualized treatment planning. Our best practice guidelines support in identifying, collecting, evaluating and implementing practices that aid in service delivery that supports member-centered interventions and desired outcomes. The following resources provide additional best practice guidelines.
- American Psychiatric Association: Assessment of Older Adults
- AACAP Practice Parameters: Reactive Attachment Disorder and Disinhibited Social Engagement Disorder
- Veterans Administration (VA)/Department of Defense (DoD) Clinical Practice Guidelines for Major Depressive Disorder
- American Psychological Association: Guidelines for PTSD
- American Psychological Association: Guidelines for Depression for Youth and Adults
- American Psychiatric Association: Psychopharmacologic treatment of Patients with Alcohol Use Disorder
- American Psychiatric Association: Antipsychotic Use to Treat Agitation or Psychosis in Patients with Dementia
Banner – University Family Care/ALTCS 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.