Appeals

Arizona law requires Arizona Complete Health (AzCH) to ensure a process for members to appeal denied claims or denied services.

• A “denied claim” is when the member has already received care, the treating provider submitted a claim, and AzCH has denied the claim.
• A “denied service” is when AzCH denies a prior authorization request for a service covered in the member’s policy that the member or treating provider believe is medically necessary. 

When AzCH denies a claim or authorization for a covered service, members receive information regarding the right to appeal the denial. The appeals process only occurs if the member or treating provider have specifically requested that AzCH reconsider its initial decision. The AzCH appeals process consists of the following levels of review:

For urgently needed services not yet provided:

1. Expedited Medical Review
2. Expedited Appeal 
3. Expedited External Independent Review

For standard services or denied claims

1. Informal Reconsideration (ONLY available for pre service denials)
2. Formal Appeal
3. External, Independent Review 

Appealable decisions by the AzCH include:

• AzCH does not approve a service that the member or treating provider have requested.
• AzCH does not pay for a service that the member has already received.
• AzCH does not authorize a service or pay for a claim because it is determined not medically necessary.
• Notification of the AzCH authorization request determination not received within 10 business days of receiving a service request.
• AzCH does not authorize a referral to a specialist.

Treating providers are not required to get any special permission to represent members in pre service Appeals proceedings.

To ensure that AzCH processes the disputes correctly, to request a post service claims payment appeal on behalf of a Plan member; please include appropriate documentation confirming authorized representation.  As a courtesy, an Appoint of Representation form is available in the resource section

Claims Payment Resubmissions and Reconsiderations

Providers have two options for resolving claims payment disputes:

1. Claims Resubmission for resubmitting claims with incorrect, or inaccurate information
2. Claims Reconsiders to request exception or review of payment accuracy

Indicate the type of review requested, “Claim Resubmission” or “Claim Reconsideration” and forward to:

Claim Resubmission

Claims Department
Ambetter from Arizona Complete Health
P.O. Box 9040
Farmington, MO 63640-9040

Claim Reconsiderations

Claims Department
Ambetter from Arizona Complete Health
P.O. Box 9040
Farmington, MO 63640-9040

Provider Grievance

Provider grievances are the expressed dissatisfaction for issues that do not qualify as appeals. Examples include:

• Provider materials (e.g. Provider Manual) inaccurate and/or insufficient
• Claims payment resubmission or reconsideration outcome
• Network provider’s difficulty reaching assigned Engagement Specialist to resolve issues
• Plan responsiveness to requests for technical assistance.

All level grievances for non-claims payment, and claims payment related provider grievances must sent in writing to:

Mail: 
Attention:  Provider Grievance
Ambetter from Arizona Complete Health 
P.O. Box 9040
Farmington, MO 63640-9040

Email: AzCHMarketplace2@azcompletehealth.com or

Fax: (866) 461-7012

AzCH acknowledges all provider grievances filed within five business days from the date of receipt of the grievance request.

AzCH does not request records to support a grievance. AzCH determines the provider grievance response based on information submitted by the provider with the grievance request and records previously received.

The Ambetter A&G Department is responsible for documenting the entirety of the provider grievance process including: initial request, scanning copy of the initial request, issuing acknowledgement of the grievance filling, research and plan response in the A&G software system.