Medical Necessity, Criteria and Standards of Care

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:

  • 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/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 by clicking on the evicore Provider Clinical Guidelines.