What Is the Adverse Determination?

This means that a requested service or a claim for service or a denial, reduction, or termination of service, in whole or in part, is:  

• Not medically necessary or appropriate, including the health care setting, level of care or effectiveness of a treatment or service
• Experimental or investigational
• Not a covered service

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. 

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. 

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 treating 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:

• Initial Appeal
• Voluntary Internal Appeal (some plans may not offer this level)
• External Independent Review

•  NEW Consumer Guide to Health Care Appeals
•  NEW Health Care Insurer Appeals Process Information Packet (revised 6/28/2024)
•  NEW Health Care Appeals Request Form
•  NEW Provider Certification Form for Expedited Medical Reviews