Standard Services or Denied Claims

Informal Reconsideration

Informal Reconsideration is the first step in the appeals process for denied services when you do not qualify for Expedited Medical Review. You may request Informal Reconsideration by calling, writing or faxing your request to your insurer. You have up to two years after your insurer denies your request for a covered service to request an Informal Reconsideration. The insurer has 30 days to make a decision and notify you and your doctor or treating provider of that decision. For denied claims, some insurers may allow you to go through the Informal Reconsideration process, or they may require that you go straight to a Formal Appeal. If the insurer still denies your request for service (or claim, if applicable) after the Informal Reconsideration is completed, you may then request a Formal Appeal.

Formal Appeal

If your insurer denies your request for a covered service after an Informal Reconsideration, you may request a Formal Appeal. You have 60 days following the completion of the Informal Reconsideration of a denied service to request a Formal Appeal. If your insurer requires appeals of denied claims to begin at the Formal Appeal level, you have up to two years after the last denial occurred to request a formal appeal of your denied claim. For denied services, your insurer has 30 days to make its decision. For denied claims, the insurer has 60 days to make its decision and notify you of the decision. If the insurer still denies your request for service or a claim for a service, you can then request an External, Independent Review.

External, Independent Review

You have four months after your insurer notifies you that your Formal Appeal was denied to request an External, Independent Review. Your insurer will send a copy of all relevant medical records, your request for review, your policy and any supporting documentation used to make its earlier decision to the Department of Insurance within five business days of receiving your External Independent Review request.

For medical necessity cases, the Department of Insurance will forward submitted materials to an independent review organization selected by the Department within five business days of receiving them. The reviewing organization, under contract with the State of Arizona to provide services to the Department of Insurance, is not connected to your health insurance company. The Department will pay the independent review organization, and will recover its costs from your health insurance company. The external, independent reviewer must generally be a doctor who is board certified or board eligible in his or her specialty. The reviewer may not have any conflict of interest that will preclude the reviewer from making a fair and impartial decision. The reviewer has 21 days to notify the Department of Insurance of its decision. The Department of Insurance then has five business days from when it receives the external, independent reviewer’s decision to notify you, your doctor (or treating provider) and your insurer of the reviewer’s decision.

For cases involving denials based on a question of coverage, the Department of Insurance has 15 business days to review the information provided and determine if the denied service or claim is covered under the policy. The Department will notify you, your doctor (or treating provider) and your insurer of its decision. If the Department is unable to determine if the claim is covered under the policy, it may then send the case to an independent review organization. If that happens, the reviewer has 21 days to send a decision to the Department and you would be notified of the decision within five business days.

The external, independent reviewer’s decision is legally binding on the insurer and you, even if you or the insurer disagrees with the decision. Either you or the insurer may go to court following the completion of the external, independent review based on an issue of medical necessity. If you or the insurer disagree with the Department of Insurance’s decision regarding coverage issues, either party may request a hearing with the Office of Administrative Hearings. Hearings must be requested within 30 days of receiving the coverage issue determination. Instructions for requesting a hearing will be sent to you along with notice of any decision made by the Department of Insurance. Please keep in mind, however, that the independent review organization, the Department of Insurance and the Office of Administrative Hearings cannot require an insurer to pay a claim or provide a service that is excluded from coverage by your policy.