How to appeal a health insurance denial in Arizona
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. Arizona lets you ask an independent reviewer to decide, through Arizona Department of Insurance and Financial Institutions. The deadline to ask: within four months after the member receives written notice of an adverse determination.
Does this apply to you? State external review covers plans regulated by Arizona: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in Arizona
Within four months after the member receives written notice of an adverse determination
For medical-necessity cases the independent review organization decides within 72 hours of receiving the case from DIFI; DIFI decides coverage questions within 2 business days. Expedited external review is available once the insurer denies at the Expedited Medical Review level (or the insurer fails to follow the rules), with certification from the treating provider.
Free
State-regulated plans (insurance bought in Arizona or through an employer that buys insurance). Self-funded employer plans use the federal process.
You send the written external review request to your insurer (its utilization review agent), which forwards it to DIFI; DIFI assigns an IRO for medical-necessity and experimental denials and decides contract-coverage disputes itself (appealable to the Office of Administrative Hearings within 30 days). Effective 1/1/2025, HB 2599 revised the process (for example, expedited external requests now get four months instead of five business days), and CMS now lists Arizona as 'Meets Parallel' (effective 1/1/2025) after previously listing it as 'Meets Similar'. Group plans may add a voluntary internal appeal level that must be requested within 60 days; DIFI's health care appeals unit is 602-364-2399 (hca@difi.az.gov).
Who to contact
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in Arizona?
Within four months after the member receives written notice of an adverse determination
Can I get a fast external review in Arizona?
For medical-necessity cases the independent review organization decides within 72 hours of receiving the case from DIFI; DIFI decides coverage questions within 2 business days. Expedited external review is available once the insurer denies at the Expedited Medical Review level (or the insurer fails to follow the rules), with certification from the treating provider.
Does external review cost anything in Arizona?
Free
Do Arizona’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- A.R.S. 20-2537: External independent review; expedited external independent review
a member may initiate an external independent review within four months after the member receives written notice by the utilization review agent of an adverse determination
- Arizona DIFI: Health Care Insurer Appeals Process Information Packet (draft rev. 4/26/2024, HB 2599 version)
There is no fee to you or your provider for any level of appeal.
- CMS CCIIO: State External Appeals Review Processes (table updated July 9, 2024)
Arizona (effective 1/1/2025)
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.