Urgently Needed Services Have Not Yet Been Provided
Expedited Medical Review
Expedited Medical Review will only apply to denied services when your doctor (or treating provider) certifies in writing that delaying the needed health care service could cause a significant negative change in your medical condition. The insurer or health plan must make a decision within one business day after receiving your doctor’s certification and any supporting documentation, and notify you and your doctor of the decision in writing. If your insurer or health plan still believes that it should not cover the requested service after the Expedited Medical Review is completed, it must inform you by phone and in writing of your right to then request an Expedited Appeal, which is described below.
If the insurer denies the requested service following the Expedited Medical Review and you still wish to appeal the denial, your treating provider must immediately submit a written appeal to the health plan and provide any additional justification or documents supporting the request for service. The insurer or health plan must make a decision within three business days after receiving the provider’s appeal request. If the insurer upholds its denial following the Expedited Appeal, the insurer must inform you and your provider by phone and in writing of the denial and of your right to immediately proceed to an Expedited External Independent Review.
Expedited External Independent Review
You have five business days after you are notified that your Expedited Appeal was denied to request an Expedited External Independent Review. Your insurer will send a copy of all relevant medical records, your policy and any supporting documentation used to make its earlier decision to the Arizona Department of Insurance within one business day of receiving your Expedited 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 two 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 72 hours to notify the Department of Insurance of its decision. The Department then has one business day 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 two 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.