Insurance companies like your business because they like your money. Sometimes, insurance companies do not like paying money to you.
The Arizona Department of Insurance protects consumers in conflicts with insurers. The state offers an appeals process when an insurance company denies a request or claim.
Decisions to appeal
You can appeal when your insurance company:
- Does not approve a service requested by you or your provider
- Does not pay for a service you already received
- Decides a service or claim is not “medically necessary”
- Decides the policy does not cover a service or claim and you disagree
- Fails to respond to your request for a service within 10 business days
- Does not approve a referral to a specialist
Appeals are not always possible. You cannot appeal a disagreement
over the amount of your copayment, rate increases or if a company decides not to insure you.
The appeals process
Either you or your provider can file an appeal. Under state law, you must first file an appeal with the insurance company. The state may get involved if you are not satisfied with the company’s response.
The appeals process depends on many factors. Chief among them is the urgency of your medical situation. Some conditions demand immediate attention. Others do not. Depending on the urgency, you can pursue either an expedited or standard review.
The process becomes complicated. Terms such as medical necessity and contract coverage may come into play. You need documentation and must meet deadlines.
The process can involve the insurance director reviewing the case. It can also include the Office of Administrative Hearings.
A good appeal
Insurance companies specialize in red tape. Their rules are complex. The government’s laws are also complex.
All you want is care for your medical condition. You can read through your policy and visit the state website for information, but it is far too easy for you to make a simple mistake that jeopardizes your appeal. When your health is at stake, always explore your options.