Banner Medicare Advantage and contracted providers use clinical information sources when making medical necessity determinations. Medical necessity criteria used by Banner Medicare Advantage in clinical decision-making includes, but is not limited to:
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.
Banner Medicare Advantage ensures that our utilization review (UR) team encompasses appropriate criteria, care, services, and benefit coverage when making medical determinations. Banner Medicare Advantage does not encourage providers or staff members to make medical determinations that cause under-utilization of treatment and/or services. Banner Medicare Advantage 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 and authorization is approved.
A member’s case is forwarded to a Banner Medicare Advantage 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.
Medicare requires the appeal process is followed for reconsiderations to an adverse decision once the decision is finalized. Inpatient level of care denials cannot be reversed by a health plan medical director once a hospital discharge order has been written.
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:
(Endorsed by Banner Medicare Advantage)
Our health plans adhere to clinical practice guidelines and regularly review our guidance.
Clinical Practice Guidelines are:
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. This collaboration allows deviation from the guideline in unique clinical situations and should be clearly substantiated in the medical record.
Our clinical practice guidelines are endorsed or developed with designated, desired outcomes and associated, standardized measures of effectiveness. These guidelines are disseminated to all affected providers and are available to all providers, members, potential members and affiliated allied health professionals upon request.
Additional guideline resources are available through the National Guideline Clearinghouse.
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