Appeals

Arizona law requires Ambetter from Arizona Complete Health (the Health Plan) to have a process for members to appeal denied claims or services.

• A “denied claim” is when the member has already received care, the treating provider submitted a claim, and the Health Plan has denied the claim.
• A “denied service” is when the Health Plan 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 Ambetter from Arizona Complete Health 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, appointed representative or treating provider specifically requests that Ambetter from Arizona Complete Health reconsider its initial decision. The member/treating provider/appointed representative has two years from the date of denial to request an appeal.

Prior to submitting an appeal for a denied service that has not yet been provided, the treating provider has the option to schedule a peer-to-peer discussion with the Health Plan medical director to discuss the denied service.

Peer-to-peer requests must be submitted within the following timeframes:

• Inpatient Denials Two business days from notice of denial or discharge date whichever is later
• Outpatient Denials 30 calendar days from the date of denial determination or Notice of Action (NOA)

Peer-to-Peer Contact Information: (833) 456-8216 (Prompt 4)

The appeals process 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 not yet provided or denied claims

• Initial Appeal
• External, Independent Review 

Treating providers are not required to obtain special permission to represent members in Appeals proceedings.

You may email, mail or fax your request. For additional process and submission details, please refer to the Appeals and Grievance Guide on the Provider Resources page.

Non-Claims Payment Provider Grievances

Examples include:

• Inaccurate and/or insufficient provider materials
• Difficulty reaching assigned Provider Engagement Specialist to resolve issues
• Lack of Health Plan responsiveness to requests for technical assistance

You may email, mail or fax your request. For additional process and submission details, please refer to the Appeals and Grievance Guide on the Provider Resources page.

Provider Claim Resolution Process

The provider claim resolution process allows providers the opportunity to challenge a decision by Ambetter from Arizona Complete Health related to payment or nonpayment of a claim or recoupment of a claim payment.

Step 1: Submit Reconsideration Request

Disagreements can frequently be resolved through our informal “Reconsideration” process. We encourage providers to attempt to resolve issues informally before initiating the formal claim appeal/provider grievance process. A “Reconsideration” is an informal request for review of a claim that you believe was incorrectly paid or denied for which submission of additional information not previously submitted is needed to further process or review the claim.

Step 2: Submit Formal Claim Appeal/Provider Grievance

If the informal reconsideration process is not successful, providers may submit a formal request to challenge a payment or denial of a claim.

To submit a reconsideration or formal claim appeal/provider grievance, please submit via the secure provider portal (preferred). A completed Provider Claim Dispute Resolution Form should always be included with your submission. Ensure the applicable resolution type is clearly checked. You may also email, mail or fax your request. For additional process and submission details, please refer to the Appeals and Grievance Guide on the Provider Resources page.