How appeals work in Arizona
When an Arizona-regulated health plan says no to a service or claim, the member usually gets an adverse determination notice. That notice should explain how to challenge the decision inside the plan—this is internal review (sometimes called an appeal or grievance).
Think of internal review as asking the insurance company to take a second look. If that fails, many Arizonans can go to external independent review, where DIFI assigns an outside doctor or clinician who does not work for the insurer.
Universal how-to (records, deadlines, urgency): Appeals roadmap and Building a strong appeal packet.
The usual steps (commercial plans)
Arizona law (Article 25 of Title 20) sets up levels of review. Not every plan has every level—the denial letter tells you which apply.
- Adverse determination — the first “no” (often after prior authorization or utilization review).
- Initial appeal — the member asks the plan to reconsider. Can often be filed orally or in writing. You generally have up to two years after the denial to start (A.R.S. § 20-2535)—but do not wait that long if care is time-sensitive.
- Voluntary internal appeal (some group or grandfathered individual plans only) — if the plan offers this extra step, you must file within 60 days of the prior denial (A.R.S. § 20-2536).
- External independent review — after internal review is finished (or skipped in urgent cases). See Arizona external review.
Some plans first offer informal reconsideration(a quick review). Check the member's packet or denial letter. DIFI's consumer guide describes the full path (DIFI — Consumer Guide to Health Care Appeals (PDF)).
Deadlines by plan type
Fully insured commercial (Arizona-regulated)
After you file an appeal, the plan must send a written answer within:
- 30 days — if the service has not been provided yet (pre-service)
- 60 days — if the service was already provided and you are fighting a claim denial
Medical necessity disputes must be reviewed by a licensed clinician with the right specialty (A.R.S. § 20-2533(L)).
Urgent / expedited path
If the treating provider certifies that a normal timeline would seriously harm the patient:
- Expedited medical review: plan decides within 72 hours (A.R.S. § 20-2534)
- Expedited appeal: plan must respond within 3 business days after the expedited appeal is filed (same statute, subsection E)
In some urgent cases you can start expedited external review at the same time as an initial appeal—see the DIFI appeals packet (DIFI — Health Care Appeals Packet (PDF)).
Marketplace (HealthCare.gov) plans
These are usually fully insured and follow Arizona's appeal article when regulated by DIFI. Federal ACA rights also apply (including up to 180 days for some federal internal appeals). See Marketplace plans.
Employer self-funded (ERISA)
Arizona's Article 25 often does notapply. Use the plan's ERISA documents and federal timelines. See Self-funded ERISA plans.
AHCCCS (Medicaid)
Appeal the health plan within the time on your Notice of Adverse Benefit Determination—often 60 days for managed care. If you still disagree, you may request a State Fair Hearing (often within 90 days of the plan's appeal decision). Start here: azahcccs.gov — grievances and appeals.
Medicare Advantage
Use Medicare's appeal system, not Arizona Article 25. See Medicare appeals.
Arizona laws to know
- A.R.S. § 20-2533 — levels of review and standard decision times
- A.R.S. § 20-2535 — initial appeal
- A.R.S. § 20-2536 — voluntary internal appeal (when offered)
- A.R.S. § 20-2534 — expedited medical review and expedited appeal
There is no charge to the member for internal or external review—the insurer pays.
What comes after internal review?
If internal review ends with a final denial of medical necessity, experimental/investigational, or similar issues, you can request external independent review through DIFI. You generally have four months from that final notice. Full instructions: Arizona external review.
Key takeaway
Read the denial letter. File internal review before the deadline on that letter (even though Arizona allows a long window for initial appeals, urgent cases need fast action). Keep copies of everything you send. If internal review fails, external review through DIFI is often the member's strongest tool on fully insured Arizona plans.