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Arizona
General Information and Internal Plan Review:
Arizona distinguishes between “denied services" (care
you have yet to receive) and "denied claims" (for
care you have already received). To appeal either, you must
start with an internal appeal. For denied services, you must
request an Informal Reconsideration (or, if urgent, an Expedited
Medical Review). For denied claims, your insurer may allow
you to begin with the Informal Reconsideration or may require
you to initiate a Formal Appeal.
If the insurer continues to deny your request, you may file a Formal
Appeal with the insurer within 60 days of the completion of the Informal
Reconsideration of a denied service or up to two years after a denied
claim. The insurer has 30 days to make a decision on denied services
and 60 days for denied claims. If the Formal Appeal is denied, you have
30 days to request an External, Independent Review.
The External, Independent Review Process:
Whom to contact: |
Your health plan |
Who can appeal: |
You, your provider,
or your authorized representative |
What you can appeal: |
Denied claims or
denied requests for services |
When you can appeal: |
You must appeal
within 30 days after receiving notification
of denied Formal Appeal or within 5 days after
an expedited appeal denial. |
What to send: |
Either write a
letter or use the request form provided in
your health plan’s information packet
and include any relevant materials to support
your case. You are not required to use the
form. |
What you must pay: |
No charge |
What will happen: |
The insurer will
send a copy of the policy, medical records,
all documents used to render the decision,
and a description of the issues and the basis
for the decision to the state Department of
Insurance (DOI).
For denials based on a coverage issue:
- Within 15 days of receiving the information,
the DOI will review and determine if
the service or claim is covered under the
policy.
- The DOI will mail a notice of the decision
to you, your health plan, and your
treating provider.
- If the DOI cannot make a decision, it
may refer the case to an independent
review organization.
For denials based on medical necessity:
- Within 5 days of receiving the information,
the DOI will send your case to an independent
review organization (IRO).
- The independent reviewer will evaluate
the case, make a decision within 21
days, and send a notice of the decision
to the DOI.
- Within 5 business days of receiving the
IRO’s decision, the DOI will
send a notice to you, your health plan,
and your treating provider.
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When you will get
a decision: |
For standard reviews
based on coverage issues: within 20 business
days from the date your request is received.
For standard reviews based on medical necessity:
approximately 36 days from the date your request
is received. |
In urgent situations: |
To be eligible
for the three-tiered expedited appeal process,
your treating provider must submit a written
certification to your insurer and send supporting
documentation indicating that waiting through
the standard appeal process is likely to cause
a significant negative change in your medical
condition at issue. After you have completed
2 internal expedited levels of review, you
may request expedited external review, which
will be completed within 3 business days (for
coverage issues) or 9 business days (for medical
necessity issues). |
How to Get More Information:
Arizona Department of Insurance, 800-325-2548 (statewide)
www.id.state.az.us/consumermore.html
Information updated as of 2-12-2004 |