Appealing a Health Claim or Service Denial
Insurance companies are required to provide you with a right to appeal a claim denial or service denial.
Review information on our Health Care Appeals web page.
- Review the Health Care Appeals Information Packet that your health insurer provided to you or review the generic version that we have on our web site. The packet contains important information about your appeal rights and the time within which you and the insurer must complete each step in the process.
- Complete the insurance company's appeal process (as described in the Health Care Appeals Information Packet).
- After your appeal has been decided by the insurance company, if you do not agree with the decision and reasoning, complete the "Health Care Appeal Request Form" to instruct the insurer to refer the appeal to us for review.
- If the insurance company denied the service or claim because they believe it was not medically necessary, we will forward your appeal to an independent review organization ("IRO"), which will evaluate the appeal and communicate its decision. The IRO's decision is final, meaning that if you do not agree with it, your only option is to decide whether to pursue a claim in Superior Court.
- If the insurance company denied the service or claim because they believe it was not covered under your policy, we will review the appeal. If you do not agree with our decision, you may request a hearing with the Arizona Office of Administrative Hearings ("OAH").
IMPORTANT: A health care appeal cannot be submitted to us unless you have completed the insurance company's appeal process. Additionally, if you initiate an appeal, you cannot submit a complaint to us until the appeal is decided, and a complaint cannot be based on dissatisfaction with the appeal decision.