[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-287400-105":53,"doc-detail-287400-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","banner-plans-and-networks-prior-authorization-form","Banner Plans and Networks - Prior Authorization Form","","This document serves as a formal Prior Authorization Request form for Banner Plans and Networks, specifically designed for healthcare providers to obtain authorization for various medical services. It encompasses categories including outpatient services, elective inpatient surgeries, acute urgent admissions, and post-acute care transitions such as SNF, rehabilitation, or LTAC. The form requires essential patient information, including demographics, health plan selection, and member identification, alongside comprehensive details about both the requesting and performing providers. Additionally, the template provides structured sections for procedure documentation, encompassing clinical codes like HCPC, CPT, and ICD-10, as well as provisions for expedited review requests for cases involving urgent health concerns. This standardized process ensures that medical necessities are properly documented and communicated to the health plan for timely review and determination, facilitating smooth care coordination for members across different insurance products, including AHCCCS and Medicare Advantage.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/banner-plans-and-networks-prior-authorization-form/287400/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/banner-plans-and-networks-prior-authorization-form/287400.png","ImageObject",442,249,{"name":88,"@type":89},"Sarah ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-27","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How should healthcare providers submit requests for outpatient services?","Question",{"text":108,"@type":109},"Requests for all outpatient services and elective inpatient surgery should be faxed to 520-874-3418 or 866-210-0512.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information is required to substantiate an expedited review request?",{"text":113,"@type":109},"An expedited review requires an explanation demonstrating that the member's life, health, or ability to regain maximum function is in serious jeopardy if the determination is not made within the standard timeframe, along with supporting documentation.",{"name":115,"@type":106,"acceptedAnswer":116},"What insurance plans are covered under this authorization form?",{"text":117,"@type":109},"The form covers AHCCCS Health Plan, Banner University Family Care/ACC, Banner University Family Care/ALTCS, Medicare, and Banner Medicare Advantage Dual HMO D-SNP plans.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},287400,1790048583,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":135,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},962085320529,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","For all Outpatient Services and Elective Inpatient Surgery and Procedures, Fax to 520-874-3418 or 866-210-0512 (please only submit to one fax number) .  \nFor all Acute Urgent Admit Notifications and Post Acute (SNF/Rehab/LTAC) admissions, Fax to 520-874-3420.  \nSubmission Type: 􀂉 AHCCCS Health Plan: 􀂉 Banner – University Family Care/ACC  \n􀂉 Medicare 􀂉 Banner – University Family Care/ALTCS  \n􀂉 Banner Medicare Advantage Dual HMO D-SNP Member Name: Last  First  MI   \nDate of Birth:   Member ID\\#:  􀂉 Inpatient 􀂉 Outpatient 􀂉 Home 􀂉 Office  \n\n| Provider making this request (Name & Provider Type):\u003Cbr>Address:   City:   State:   Zip:   NPI:   TID:   Phone \\#:  􀂉 In-Network 􀂉 Out-of-Network | Provider to perform the request (if applicable):\u003Cbr>___________________________________________________\u003Cbr>Specialty Type:   Address:   City:   State:   Zip:   NPI:   TID:  \u003Cbr>Continuity of Care: 􀂉 Yes 􀂉 No |\n| --- | --- |\n| * Name/Direct Contact (Requesting Provider office):\u003Cbr>Backline \\#:   Ext:   Fax \\#:   Office Email:   | If member is currently in an active course of treatment, please enter number of months remaining and description of treatment: |\n| Facility Information (Outpatient/Inpatient Only) Name:   Address:   City:   State:   Zip:   Phone \\#:   NPI:   TID:   | Procedure Requested:   Description:   Date of Procedure (if sched):   HCPC/CPT Code:  \u003Cbr>HCPC/CPT Code:   ICD-10 Code:  \u003Cbr>ICD-10 Code:   |\n| Expedite-Defined as member’s life, health or ability to regain maximum function is in serious jeopardy if determination is not made in the standard time frame. Request must include supporting documentation to substantiate an expedited review.\u003Cbr>Explanation\u003Cbr>Required: |  |","cbCaibkaThlgLy4T","https://ap.wps.com/l/cbCaibkaThlgLy4T","pdf",290064,6,"English","# Prior Authorization Submission Guidelines\n## Provider and Facility Information\n## Member and Procedure Details\n## Expedited Review Request","[{\"question\":\"How should healthcare providers submit requests for outpatient services?\",\"answer\":\"Requests for all outpatient services and elective inpatient surgery should be faxed to 520-874-3418 or 866-210-0512.\"},{\"question\":\"What information is required to substantiate an expedited review request?\",\"answer\":\"An expedited review requires an explanation demonstrating that the member's life, health, or ability to regain maximum function is in serious jeopardy if the determination is not made within the standard timeframe, along with supporting documentation.\"},{\"question\":\"What insurance plans are covered under this authorization form?\",\"answer\":\"The form covers AHCCCS Health Plan, Banner University Family Care/ACC, Banner University Family Care/ALTCS, Medicare, and Banner Medicare Advantage Dual HMO D-SNP plans.\"}]","Banner Plans and Networks - Prior Authorization Form | PDF",1789632291]