Medical Necessity Criteria & Clinical Practice Guidelines

Medical Necessity Criteria

Under Banner University Health Plans (BUHP), our medical necessity criteria and clinical practice guidelines are applicable to:

  • Banner – University Family Care/AHCCCS Complete Care (BUFC/ACC)
  • Banner – University Family Care/Arizona Long Term Care System (BUFC/ALTCS)
  • Banner – University Care Advantage HMO SNP (BUCA)

BUHP and contracted providers use clinical information sources when making medical necessity determinations. Medical necessity criteria used by BUHP in clinical decision-making includes, but is not limited to:

  • AHCCCS Medical Policies and Guides (AMPM/ACOM)
  • MCG Care Guidelines
  • National Practice Guidelines and Standards
  • Evidence-based Guidelines
  • Clinical Practice Guidelines (Endorsed by BUHP)
  • Member-specific information, which includes health history and social determinants.

The criterion used supports clinical decision-making that leads to effective health care practices and improved quality of care to our members. 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. The criterion does not replace a provider’s clinical judgement, and instead allows the provider to utilize the criteria towards the member’s health care needs. This collaboration allows deviation from the guidelines in unique clinical situations and should be clearly substantiated in the medical record.

BUHP ensures that our utilization review (UR) team encompasses appropriate criteria, care, services, and benefit coverage when making medical determinations. BUHP does not encourage providers or staff members to make medical determinations that cause under-utilization of treatment and/or services. BUHP employees are not provided financial incentives or rewards that causes under-utilization of services and/or treatment. A member’s condition or treatment requirements does not replace the provider’s judgement when and authorization is approved.

A member’s case is forwarded to a BUHP Medical Director for review and determination when the clinical documentation provided does not meet the criteria. A member’s case may be discussed with our Medical Director upon an attending physician’s request.

  • To request the clinical basis or criteria used when making medical necessity determinations from BUHP, please fax our Utilization Management Department at (520) 874-3420 or call:
    • BUFC/ACC: (800) 582-8686
    • BUFC/ALTCS: (833) 318-4146
    • BUCA: (877) 874-3930
  • To discuss an adverse decision with our BUHP Medical Director, please call the Utilization Management Department within five (5) business days of the determination.

Please Note:

Claim payments are not guaranteed when an authorization is submitted and approved; it is based on medical necessity review, proper coding, and covered benefits. Payment is dependent on the member’s eligibility at the time of service and/or treatment. To verify a member’s eligibility, please call:

  • BUFC/ACC: (800) 582-8686
  • BUFC/ALTCS: (833) 318-4146
  • BUCA: (877) 874-3930

Clinical Practice Guidelines 

(Endorsed by BUFC/ACC, BUFC/ALTCS, and BUCA)

Our health plans adhere to clinical practice guidelines and regularly review our guidance. 

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 our members;
  • Adopted in consultation with our 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;
  • 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.

Our 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

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