Banner Health Plans (BHP) and contracted providers use clinical information sources when making medical necessity determinations. Medical necessity criteria used by BHP 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 BHP)
- 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.
BHP ensures that our utilization review (UR) team encompasses appropriate criteria, care, services, and benefit coverage when making medical determinations. BHP does not encourage providers or staff members to make medical determinations that cause under-utilization of treatment and/or services. BHP 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 an authorization is approved.
A member’s case is forwarded to a BHP 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 BHP, please fax our Utilization Management Department at 520-874-3420 or call:
- Banner – University Family Care/ACC (B – UFC/ACC): 800-582-8686
- Banner – University Family Care/ALTCS (B – UFC/ALTCS): 833-318-4146
To discuss an adverse decision with our BHP 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:
- B – UFC/ACC: 800-582-8686
- B – UFC/ALTCS: 833-318-4146
Medical Necessity Criteria for Admissions to Therapeutic Foster Care for Children
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.
Medical Necessity Criteria for Admission to a Behavioral Health Residential Facility
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Learn more about Medical Necessity Criteria for Admissions to BHRF.
Medical Necessity Criteria for Admissions to Adult Behavioral Health Therapeutic Home
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.
Medical Necessity Criteria for Behavioral Health Inpatient Facility for Children and Youth
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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