This web page is intended to provide a brief description of the health care appeals process. A more detailed explanation is provided in the Health Care Appeals Information Packet available from your health insurer. If you file a complaint with the Department of Insurance related to a denial that is subject to the appeals process, the Department must first require you to pursue the appeals process at your insurer. The Department will not otherwise address your complaint during the appeals process, except to the extent your complaint alleges an independent violation of the Insurance Code other than the denial of your claim or request for service.
What Is the Health Care Appeals Process?
Arizona law requires health insurers, HMOs, dental plans, prepaid dental plans and vision plans to provide their insured members with a way to appeal denied claims or denied services. A “denied claim” is when you have already received care, submitted a claim, and the insurer has denied the claim. A “denied service” is when the plan refuses to authorize a service that is covered by the plan, such as a referral to a specialist, or the plan refuses to pre-authorize any treatment or procedure that you or your doctor believe is medically necessary and covered by your policy. When your health insurer denies a claim or service, it must advise you of your right to appeal the denial. Please keep in mind that the appeals process will normally not occur unless you (or your provider) have specifically requested that your insurer or plan reconsider its decision. The appeals process generally consists of the following levels of review:
For urgently needed services not yet provided:
- Expedited Medical Review
- Expedited Appeal
- Expedited External Independent Review
For standard services or denied claims
- Informal Reconsideration
- Formal Appeal
- External, Independent Review