New to helping someone in Arizona?
You do not need to be a lawyer to help. Start with three items from the patient or family:
- Insurance card — shows which company and plan type (Marketplace, employer, Medicaid, etc.)
- Denial letter or EOB — explains what was denied and usually lists appeal deadlines
- Summary of Benefits and Coverage (SBC) — if you have it; summarizes what the plan covers
Your job at first is simple: figure out what kind of plan this is and what deadline the letter gives you. Arizona commercial plans often use words like "adverse determination," "initial appeal," and "external independent review." The denial letter is still your roadmap.
For steps that work in every state (understanding the denial, gathering records, asking for urgent review), use these general guides first, then come back here for Arizona rules:
What is different in Arizona?
- HealthCare.gov Marketplace: Arizona does not run its own exchange. Individual plans are bought on HealthCare.gov. For 2026, seven carriers sell Marketplace plans (Ambetter/AZ Complete Health, Antidote, BCBS Arizona, Cigna, Imperial, Oscar, UnitedHealthcare). On the exchange, plans are HMO only—no PPO option with subsidies (healthinsurance.org — Arizona Marketplace).
- State prior authorization law: Arizona sets clear PA deadlines—5 days for urgent, 14 days for non-urgent—and treats silence as approval if the plan misses the deadline (A.R.S. § 20-3404).
- Layered appeals (commercial plans): Many disputes move through an initial appeal, sometimes a voluntary internal appeal (certain employer or grandfathered plans), then external independent review through the Arizona Department of Insurance and Financial Institutions (DIFI). DIFI picks an outside reviewer (IRO) who does not work for the insurance company.
- External review filing: You usually send your external review request to the insurance company first; the company forwards materials to DIFI. You generally have four months after the last internal denial (A.R.S. § 20-2537).
- AHCCCS (Medicaid) is separate: Medicaid appeals and fair hearings follow AHCCCS rules—not the commercial insurance statutes above.
Who is in charge of your plan?
- Arizona DIFI (Department of Insurance and Financial Institutions): Oversees many fully insured health plans, consumer complaints, and external independent review — difi.az.gov — Health. Consumer help: (602) 364-2499 or 1-800-325-2548.
- U.S. Department of Labor: Many self-funded employer plans.
- AHCCCS: Arizona Medicaid — azahcccs.gov — grievances and appeals.
- CMS: Medicare and Medicare Advantage.
After appeals are exhausted, you can also file a complaint with DIFI — see Regulator complaints.