Banner – University Family Care/ACC (B – UFC/ACC) and our providers use information to help us when reviewing a prior authorization. The standards we use in clinical decision-making includes:
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/ACC 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/ACC 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/ACC 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 Clinical Practice Guidelines page. Clinical Practice Guidelines are recommendations to support clinical decision-making.
Banner Utilization Management may use nationally recognized coverage guidelines, including MCG Health and EviCore, when specific guidelines are not established by Medicare.
EviCore coverage criteria guidelines can be found on the EviCore Provider Clinical Guidelines webpage.
Therapeutic Foster Care (TFC) is a covered behavioral health service when medically necessary, that provides daily therapeutic interventions within a licensed family setting. These services are designed to maximize the member's ability to live and participate in the community and to function independently, including assistance in the self-administration of medication and any ancillary services (such as living skills and health promotion) indicated by the member's Treatment Plan as appropriate.
Learn more about Medical Necessity Criteria for Admissions to TFC for Children.
A Behavioral Health Residential Facility (BHRF) is a health care facility, licensed by Arizona Department of Health Services, pursuant to A.A.C. Title 9, Chapter 10, Article 7 (Behavioral Health Residential Facility). Medical necessity for admission to a BHRF may be based on a number of factors, including a patient's mental health diagnosis, their ability to function, and their level of distress.
Learn more about Medical Necessity Criteria for Admissions to BHRF.
An Adult Behavioral Health Therapeutic Home (ABHTH) is a licensed residence that provides behavioral health treatment, which maximizes the ability of an individual experiencing behavioral health symptoms to live and participate in the community and to function in an independent manner that includes assistance in the self-administration of medication and any ancillary services (such as living skills and health promotion) indicated by the member's Treatment Plan, as appropriate.
Learn more about Medical Necessity Criteria for Admissions to ABHTH.
Behavioral Health Inpatient Facility (BHIF) services provide treatment for children and adolescents who demonstrate severe and persistent psychiatric disorders, when ambulatory care services in the community or services in a less restrictive therapeutic level of care do not meet their treatment needs and they require services under the direction of a Behavioral Health Medical Professional (BHMP). These services are designed for children and adolescents who have a DSM 5/ICD-10 psychiatric diagnosis, significant deficits in functioning, and who require active treatment in a controlled environment with a high degree of psychiatric oversight, 24-hour nursing services, comprehensive programming and treatment. Active treatment focuses on specific targeted goals identified by the Child and Family Team (CFT) and are designed to enable the child/adolescent to be discharged at the earliest possible time. A lack of available outpatient services or services in a less restrictive therapeutic level of care is not, in and of itself, the sole criterion for admission to a BHIF.
Learn more about Medical Necessity Criteria for Admissions to BHIF.
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