Arizona: fighting a health insurance denial

Which plan do you have? Who to call first, by coverage

Your employer pays claims itself

Arizona usually cannot help with these plans. Call the Employee Benefits Security Administration.

Call 1-866-444-3272
Insurance you buy, or an employer plan bought from an insurer

Call Arizona Department of Insurance and Financial Institutions (DIFI). See the at-a-glance box.

Call (602) 364-2499
Medicaid or children's coverage

Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Arizona.

Medicaid in Arizona
Medicare

Arizona State Health Insurance Assistance Program (SHIP), run by the Arizona Department of Economic Security, Division of Aging and Adult Services gives free counseling. Or call 1-800-MEDICARE.

Call 1 (800) 432-4040 1-800-633-4227

The short version for Arizona

Arizona runs its own external review, called External Independent Review, through the Arizona Department of Insurance and Financial Institutions (DIFI). You get two years to start an appeal with your insurer and four months after the final internal denial to ask for the outside review, it is free, and you send the request to your insurer, which must pass it to the state. Arizona has no separate consumer assistance program or ombudsman for health insurance, so the Department's Consumer Services line is the main source of free help, and the Department will not look at a complaint about a denial until you have used the appeal process.

At a glance: independent review for plans Arizona regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator: Arizona Department of Insurance and Financial Institutions (DIFI) · (602) 364-2499 (Spanish: (602) 364-2977). Consumer help is available Monday to Friday, 9 AM to 4 PM, except state holidays.
Independent review: A state process (External Independent Review (and Expedited External Independent Review for urgent cases))
Deadline to request it: Four months after you receive the insurer's final internal denial (the same four months applies to an expedited request). Separately, you have two years from the date of the original denial to start the first internal appeal with your insurer.
Cost: None. There is no fee to you or your provider for any level of appeal; the Department pays the independent review organization and bills the insurer.
Decision time: Medical necessity cases: the independent review organization has 21 days after it gets the case from the Department (the Department may allow up to 10 more days for good cause), and the Department then has five business days to send you the decision. Before that, the insurer has five business days to send your file to the Department and the Department has five days to choose the review organization. Coverage cases: the Department decides within 15 business days after it receives the file from the insurer.; fast track: Medical necessity cases: the independent review organization decides within 72 hours of getting the case, and the Department sends the decision within one business day after that. The insurer must forward the file within one business day and the Department must assign the case within two business days. Coverage cases: the Department decides within two business days after it receives the file.

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

The Department says to check your member ID card. Self-funded employer plans, which are generally regulated by the U.S. Department of Labor and not by Arizona, often show one of these phrases near the insurer's name: "Administered by," "As administrator for," "Administrative services only," or "ASO." Insured plans may show "Underwritten by" or "Insured by." Starting in 2022, ID cards must display "AZDOI" if the coverage is not self-funded, Medicare or Medicaid, so "AZDOI" on your card means Arizona regulates the plan. If you are unsure, ask your employer's benefits office.

Arizona Department of Insurance and Financial Institutions (DIFI)
Health coverage that is insured under Arizona law: plans from health insurers, health maintenance organizations (HMOs), dental plans, prepaid dental plans and vision plans, whether you bought the plan yourself or get an insured plan through an employer. The Department says it cannot handle Medicaid (the Arizona Health Care Cost Containment System), Medicare, TriCare, COBRA (continuation of employer coverage under the Consolidated Omnibus Budget Reconciliation Act) or self-funded employer health plans.

Phone: (602) 364-2499 (Spanish: (602) 364-2977). Consumer help is available Monday to Friday, 9 AM to 4 PM, except state holidays.. File a complaint online

Independent (external) review

Process: A state process. Run by Arizona Department of Insurance and Financial Institutions. For medical necessity and experimental or investigational denials, the Department picks an independent review organization under contract with the state to decide the case. For denials that say a service is not covered by the policy, the Department itself decides, and may send the case to an independent review organization if it cannot decide.
Where you file: insurer
How: Send a written request for External Independent Review to your insurer, using the appeals address in the Health Care Insurer Appeals Process Information Packet your insurer must give you, and include any documents that support your case. The insurer must acknowledge it and send your file to the Department within five business days (one business day for an expedited request); you then have five business days after getting that notice to send extra written evidence to the Department. For general questions about the process, call the Department's Consumer Services number at (602) 364-2499.
Which denials qualify: Any "adverse determination": a denial, reduction or ending of a service, or a denied claim, because the insurer says it is not medically necessary or appropriate (including the care setting, level of care or effectiveness), is experimental or investigational, or is not a covered service. It also covers a rescission, meaning the insurer cancels your policy back to its start date for a reason other than unpaid premiums. There is no minimum dollar amount. The state appeals packet says these are not eligible: disagreements about the amount the insurer paid, how benefits are coordinated between two insurers, or your copayments, coinsurance or deductible. The reviewers cannot order an insurer to pay for something the policy excludes.
Appeal to the plan first?: Yes. You must first complete the insurer's Initial Appeal, and the Voluntary Internal Appeal if your plan offers that second level. Exceptions the state gives: the insurer may waive its internal appeals and send the case straight to external review; you are treated as having finished the internal appeals if the insurer does not follow the appeal law's requirements (unless you asked for or agreed to the delay); and in urgent cases you can ask for an Expedited External Independent Review at the same time as an internal review. For an expedited case, your treating provider must certify in writing that the time needed for a standard appeal is likely to cause a significant negative change in your medical condition.
Published results: No recent figures found. The most recent breakdown we found is for fiscal year 2014: of 148 cases decided by independent medical review organizations, 55 were overturned or partly overturned in the consumer's favor (about 37%); of 60 coverage cases decided by the Department, 7 were overturned or partly overturned (about 12%). These numbers are more than ten years old and predate changes to the law that took effect January 1, 2025. Source

Official page

General rules and what to send: how external review works, how to request it.

Free help in Arizona

Arizona Department of Insurance and Financial Institutions, Insurance Consumer Services
Answers questions about the health care appeals process and takes complaints about state-regulated insurers; for a denial it will require you to use the appeal process first, and it cannot give legal advice or act as your lawyer.

Phone: (602) 364-2499
U.S. Department of Labor, Employee Benefits Security Administration
The federal contact listed for Arizona residents with a question, complaint or dispute about coverage from a self-insured employer plan, which the state insurance department does not regulate.

Phone: (866) 444-3272
Disability Rights Arizona (formerly the Arizona Center for Disability Law)
Free legal information, advice and some direct representation for people with disabilities who are denied medically necessary services or eligibility, mainly in Arizona Medicaid and the Division of Developmental Disabilities; it screens requests through an intake process and does not take every case.

Phone: (602) 274-6287 or (800) 927-2260 (Phoenix); (520) 327-9547 or (800) 922-1447 (Tucson)

Medicare and Medicaid in Arizona

Medicare counseling: Arizona State Health Insurance Assistance Program (SHIP), run by the Arizona Department of Economic Security, Division of Aging and Adult Services · 1 (800) 432-4040 (leave a message and a counselor will call you back) . Free help with Medicare appeals.
Medicaid agency: Arizona Health Care Cost Containment System (AHCCCS), Arizona's Medicaid agency
Fair hearing deadline: Use the deadline printed on your Notice of Appeal Resolution. The agency's own web page does not give a number of days. The state rule text we found says the written request must be received no later than 30 days after you receive the Notice of Appeal Resolution, while some health plans tell members they have 90 days. To be safe, ask in writing within 30 days. Your notice states the deadline that applies to you.
Good to know: If you are in an AHCCCS health plan, you must appeal to the health plan first (state rule: within 60 days after the date of the denial notice); a State Fair Hearing before an administrative law judge is available only after the plan's appeal decision. If waiting 30 days would seriously endanger your health, ask for an expedited appeal, which should be resolved within three working days. To keep services that are being reduced, suspended or ended, file the appeal before the change takes effect, or within 10 days from the notice date if there are fewer than 10 days between the notice date and the effective date; if you lose, you may have to pay for those services. Members not in a health plan (fee-for-service or the American Indian Health Program) appeal in writing to the AHCCCS Office of the General Counsel. For questions, call that office at 602-417-4232 in Maricopa County or 1-800-654-8713 ext. 74232 statewide.

Medicaid appeals page How Medicaid appeals work

State laws that can help

External review. After the insurer's internal appeals, you have four months to ask for a free outside review that is binding on the insurer, and the insurer must provide the service or pay the claim without delay if you win.

Arizona Revised Statutes section 20-2537, as amended by House Bill 2599 (Laws 2024, chapter 178), effective January 1, 2025
Other. You have up to two years after a denial to ask your insurer for an initial appeal, you may ask by phone or in writing, and the insurer cannot set a minimum dollar amount for a claim to be appealed.

Arizona Revised Statutes sections 20-2535(A) and 20-2533(A)
Denial notice. When an insurer denies a claim or service it must tell you about your right to appeal, its written appeal decisions must give the basis, criteria used, clinical reasons and rationale, and it must give you its state-approved appeals information packet on request and post it on its website.

Arizona Revised Statutes section 20-2533(E), (H) and (I)
Prior authorization. A health plan must answer a prior authorization request within five days for urgent care and 14 days for other care after it has the needed information, must state the specific reason for any denial, and the request is treated as approved if the plan misses the deadline.

Arizona Revised Statutes section 20-3404
AI in utilization review. Before an insurer denies a provider's claim or prior authorization request for medical necessity, a medical director must personally review the denial using independent medical judgment and may not rely solely on recommendations from any other source, such as an automated tool.

Arizona Revised Statutes sections 20-3103 and 20-3407, added by House Bill 2175 (Laws 2025, chapter 165), effective from and after June 30, 2026
Step therapy. If your plan makes you try other drugs first, you and your prescriber can ask for an exception, which must be granted on listed grounds (for example the required drug is likely to harm you, is expected not to work, or you already tried it) and must be answered within 72 hours, or 24 hours in urgent cases, or it is treated as granted.

Arizona Revised Statutes section 20-3654
Mental health parity. Arizona's Jake's Law requires state-regulated insurers to follow the federal Mental Health Parity and Addiction Equity Act and gives the state insurance department clear authority to enforce it, so limits on mental health and substance use care cannot be stricter than limits on medical and surgical care.

Arizona Revised Statutes section 20-3502 (Senate Bill 1523 of 2020, "Jake's Law")
Surprise billing. For a surprise out-of-network bill of at least $1,000, you can ask the state insurance department for a free dispute resolution process (a settlement conference, then arbitration) within one year of the date of service; the Department says this state program is for plan years that began before January 1, 2022, and the federal No Surprises Act covers newer plans.

Arizona Revised Statutes sections 20-3111 through 20-3119

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on 2026-11-11. Phone numbers and deadlines change; check the official page before you rely on one.

Not confirmed (14)

The independent review request form. null. The Department publishes a Health Care Appeals Request Form and a Provider Certification Form, linked from https://difi.az.gov/health-care-appeals, but difi.az.gov blocks automated access with a bot check, so the direct PDF addresses of the current forms could not be captured. The only packet PDF reachable on the Department's site was a draft marked 'revised 4-26-24'. The form is optional; an insurer cannot reject an appeal for not using it.
Not confirmed. externalReview.url and all other difi.az.gov pages — read through a text-retrieval service because direct requests to difi.az.gov returned HTTP 403 (bot check). Page text was confirmed; the pages were not seen in a normal browser.
Not confirmed. externalReview.eligibleDenials, externalReview.fee and externalReview.mustExhaustInternalFirst — the list of disputes that are not eligible, the 'no fee for any level of appeal' wording and the 'simultaneously at any internal level' wording come from the state's information packet (revised 6/28/2024) as posted by an insurer (UnitedHealthcare of Arizona), because the Department's own final packet PDF could not be opened. The statute (20-2533(H)(8)) and the Department's draft packet separately confirm there is no cost to the member.
The deadline to request independent review. the Department's older Consumer Guide PDF (version dated 2021-10-28, still online at difi.az.gov/sites/default/files/Consumer_Guide_to_Health_Care_Appeals_202110.pdf) says an expedited external review must be requested within five business days and uses the old level names (Informal Reconsideration, Formal Appeal). The current statute and the 2024 packet say four months for both standard and expedited requests, effective January 1, 2025. We used the current statute.
Not confirmed. externalReview (statute status) — the Arizona Legislature's page for section 20-2537 carries the label '(Conditionally Rpld.)' with no explanation. The text on that page matches the Department's current description, and the federal list shows Arizona as meeting federal standards effective 1/1/2025, but the meaning of the label was not resolved.
Published results of independent review. figures are from the fiscal year 2014 annual report (the newest outcome breakdown found); the percentages are our own arithmetic from the published counts (33 + 22 of 70 + 78 cases; 7 of 60 cases). The 2023/2024 annual report has no outcome breakdown.
A searchable list of past decisions. null; no searchable database of past external review decisions was found.
The state regulators. a toll-free number, (800) 325-2548, appears in the Department's 2023/2024 annual report directory and on an older appeal form, but not on the current Agency Directory or complaint pages, so it was left out. The current Agency Directory lists (602) 364-3100 as the general complaint line and (602) 364-2399 / hca@difi.az.gov for the Health Care Appeals section; (602) 364-2499 is the Consumer Services number printed on the complaint page and in the appeals packet.
The Medicaid fair hearing deadline. sources conflict. The agency's Grievance and Appeals page gives no number of days. Unofficial copies of Arizona Administrative Code R9-34-217 (health plan members) and R9-34-314 (fee-for-service members) say 30 days after receiving the Notice of Appeal Resolution; Blue Cross Blue Shield of Arizona Health Choice also says 30 days; Arizona Complete Health and Molina say 90 days; a UnitedHealthcare Community Plan document refers to 90 to 120 calendar days. The official Arizona Administrative Code text was not loaded.
Not confirmed. medicaid.notes (60 days to appeal to the health plan) — taken from an unofficial copy of Arizona Administrative Code R9-34-209 and from health plan websites; the agency's own page states 60 days only for appeals by members with a Serious Mental Illness designation.
Free consumer help programs. http://www.askebsa.dol.gov is copied as printed on the Centers for Medicare & Medicaid Services Arizona page; the address itself was not loaded.
Free consumer help programs. the Centers for Medicare & Medicaid Services Arizona page lists no Consumer Assistance Program or ombudsman for Arizona, only the insurance department. The Arizona Attorney General was not listed because no page was found saying it handles health insurance denials.
Not confirmed. stateLaws (surprise-billing) — the Department's consumer page says the Arizona program is for plan years that began before January 1, 2022; the program's own page does not repeat that limit. The $1,000 minimum and one-year deadline are from Arizona Revised Statutes section 20-3114.
Not confirmed. stateLaws (ai-in-utilization-review) — the enacted text does not use the words 'artificial intelligence'; it requires individual review by a medical director. The session law says 'effective from and after June 30, 2026'; the codified sections on azleg.gov were not loaded separately.

Arizona

Which plan do you have? Who to call first, by coverage

Your employer pays claims itself

Insurance you buy, or an employer plan bought from an insurer

Medicaid or children's coverage

Medicare