Medical Necessity Criteria & Clinical Practice Guidelines
Under Banner – University Health Plans (B – UHP), our medical necessity criteria and clinical practice guidelines are applicable to:
- Banner – University Family Care/AHCCCS Complete Care (B – UFC/ACC)
- Banner – University Family Care/Arizona Long Term Care System (B – UFC/ALTCS)
B – UHP and contracted providers use clinical information sources when making medical necessity determinations. Medical necessity criteria used by B – UHP 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 B – UHP)
- 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.
B – UHP ensures that our utilization review (UR) team encompasses appropriate criteria, care, services, and benefit coverage when making medical determinations. B – UHP does not encourage providers or staff members to make medical determinations that cause under-utilization of treatment and/or services. B – UHP 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 B – UHP 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 B – UHP, please fax our Utilization Management Department at (520) 874-3420 or call:
- B – UFC/ACC: (800) 582-8686
- B – UFC/ALTCS: (833) 318-4146
To discuss an adverse decision with our B – UHP 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:
- B – UFC/ACC: (800) 582-8686
- B – UFC/ALTCS: (833) 318-4146
(Endorsed by B – UFC/ACC, and B – UFC/ALTCS)
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
- Antithrombotic Therapy and Prevention of Thrombosis
- AHCCCS Behavioral Health System Practice Tools: AMPM 200
- Arizona Opioid Prescribing Guidelines
- Asthma Care Quick Reference
- Atrial Fibrillation
- Attention Deficit/Hyperactivity Disorder in Children
- Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
- Breast Cancer Guidelines
- Cancer Network (login required to access guidelines)
- 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
- 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
- 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
- Preventative Pediatric Health Care
- Preventive Services Recommendations for Adults
- 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
Behavioral Health Guidelines
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