Prior Authorizations & Referrals
If Prior Authorization (PA) is required, the Primary Care Provider (PCP) or specialty care provider will complete the Prior Authorization Form, attach supporting documentation and fax to the Prior Authorization Department. Some medications (including non-generic medications) require Prior Authorization. For Pharmacy Prior Authorization, please complete a non-formulary drug prior authorization and fax to the Hospital and Pharmacy Coordinator.
- Services that are outside the scope of the PCP, may be referred to a contracted specialty care provider. The PCP will complete the Referral Form or acceptable substitute and fax it to the specialty care provider’s office along with applicable test results and other pertinent documents.
- Primary care providers, specialists, hospitals and vendors should fax Prior Authorization requests to the Prior Authorization Department.
- If PA is not required, per the Prior Authorization Grid, the PCP must refer the patient with a form of written instruction (i.e. note on prescription pad or Referral Form) with reason for visit (consult only – consult & treat, diagnosis, findings, etc.) to present to the specialty care provider.
- Specialty care providers must obtain Prior Authorization from the Prior Authorization Department for all services as listed on the Prior Authorization Grid.
To request an PA, fax your request to the health plans and use the fax number on the PA form. We use RightFax Computer System, which reproduces the referral electronically. This is the preferred method for obtaining authorization. Submit your request on a completed Prior Authorization Form. Please ensure that the provider’s name and fax number are clearly noted on the form. Please note whether the request is Standard or Expedited.
Prior Authorization Forms
Please include ALL pertinent clinical information with your Medical/Pharmacy Prior Authorization (PA) request submission. To ensure that prior authorizations are reviewed promptly, submit request with current clinical notes and relevant lab work.
*Providers must use the “Expedited” request only when medically necessary. Note: Inappropriate Expedited requests may be downgraded to a Standard request by BUHP.
Prior Authorization Grids/Codes
Services Requiring Prior Authorization
The Prior Authorization Grids are your source for determining what services require Prior Authorization. Be sure to reference the date of the grid since revisions to the grid may occur.
Always refer to the AHCCCS Medical Policy Manual (AMPM) Chapter 300 for coverage issues:
Medical Necessity, Criteria and Standards of Care
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.
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
Note: By clicking on any of the links below, you will be leaving our website.
- AIDS / HIV Information
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- 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
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- Attention Deficit/Hyperactivity Disorder in Children
- Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
- Cancer Network (login required to access guidelines)
- Choosing Wisely Campaign
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- Eating Disorders in Children and Adolescents
- Elder Abuse and Neglect Screening and Resources
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- Hospital Acquired Infections and Antibiotic Resistance
- Hypertension/JNC-8 Guidelines
- 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
- Obesity in Adults
- 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
- Preventive Services Recommendations for Adults
- Refugee Health Program
- Screening for Functional Decline in Older Adults
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- US Preventative Services Task Force