Medicare Advantage plans are required by CMS to provide the same medical benefits to Medicare Advantage members as original Medicare. As such, whenever possible, Medicare Advantage medical necessity decisions are based on general coverage and benefit conditions included in traditional Medicare coverage manuals, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs) used in conjunction with an LCD, when available.
If there is no applicable NCD, LCD, or LCA (used in concert with an LCD), for the service under review, then other evidence-based criteria may be applied. In addition, each member’s unique clinical situation is considered in conjunction with current CMS guidelines.
The following hierarchy is used to determine Medicare Advantage Medical Policy:
Banner Health has contracted with eviCore healthcare to provide services for members enrolled in Banner Medicare Advantage plans. Learn more at the links below.
Please include ALL pertinent clinical information with your Medical or Pharmacy Prior Authorization request submission. To ensure that prior authorizations are reviewed promptly, submit request with current clinical notes and relevant lab work.
Electronic prior authorization (ePA) helps you spend less time on PA’s and more time on patients.
Some Electronic Health Records come equipped with ePA, but if yours doesn’t, there are online options such as Surescripts, CoverMyMeds, and ExpressPAth.
Learn about and submit your PA to an online ePA portal here.
*Providers must use the “Expedited” request only when medically necessary.