Prior Authorizations Forms

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Prior Authorization Process

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: 

  1. CMS Coverage Manuals or other CMS-Based Resource: Coverage provisions in interpretive manuals are instructions that are used to further define when and under what circumstances items or services may be covered (or not covered)
  2. National Coverage Determinations (NCD) 
    a. Local Coverage Determinations (LCD)
    b. Local Coverage Articles (LCA), when used on conjunction with LCD
  3. In the absence of an applicable NCD, LCD, or other CMS published guidance, Banner Medicare Advantage plan(s) utilizes third party clinical guidelines that reflect the Generally Accepted Standards of Medical Practice scientific evidence.

Clinical 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.

MCG Clinical Guidelines

Banner Health has contracted with eviCore healthcare to provide services for members enrolled in Banner Medicare Advantage plans. Learn more at the links below.

Submitting for Prior Authorization

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.

  • Banner Prime and Banner Plus Medical Prior Authorization Form     English
  • For the Banner Dual Medical Prior Authorization Form click HERE

For increased efficiency and advanced Prior Authorization experience, please submit your PA electronically.

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.

  • Pharmacy Prior Authorization Form     English