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.
| 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 |
