Banner Medicare Advantage 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.
Banner Medicare Advantage 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. Banner Medicare Advantage does not reward employees and providers to decrease the care or services needed by our members.
If our review team denies a service authorization request, a Banner Medicare Advantage 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.
View the EviCore coverage criteria guidelines.
Banner Health uses MCG Guidelines to help review medical necessity for heath service requests. MCG Guidelines are the protected intellectual property of MCG. Banner Health is not able to distribute them without the permission of MCG. MCG has provided a tool that allows Banner Health members and prospective members to view relevant MCG Guidelines, however you will not be able to print them.
Follow the instructions below for access to MCG Guidelines.
Access Instructions:
Step 1: Click Below button to access the MCG Guidelines. Read the disclaimer and accept the terms and conditions.
Step 2: Complete the User Information Form.
Step 3: Complete the verification process to continue.
Step 4: Click on the arrow icon.
Step 5: Click on the guidelines you wish to view.