A. Notwithstanding article 1 of this chapter and subject to subsection B of this section, this article applies to all utilization review decisions made by utilization review agents and health care insurers operating in this state.

Terms Used In Arizona Laws 20-2531

  • Action: includes any matter or proceeding in a court, civil or criminal. See Arizona Laws 1-215
  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Benefits based on the health status of the insured: means a contract of insurance to pay a fixed benefit amount, without regard to the specific services received, to a policyholder who meets certain eligibility criteria based on health status including:

    (a) A disability income insurance policy that pays a fixed daily, weekly or monthly benefit amount to an insured who is deemed to have a disability as defined by the policy terms. See Arizona Laws 20-2501

  • Claim: means a request for payment for a service already provided. See Arizona Laws 20-2501
  • Contract: A legal written agreement that becomes binding when signed.
  • Covered service: means a service that is included in a policy, evidence of coverage or similar document that specifies which services, insurance or other benefits are included or covered. See Arizona Laws 20-2501
  • Denial: means a direct or indirect determination regarding all or part of a request for any service or a direct determination regarding a claim that may trigger a request for review or reconsideration. See Arizona Laws 20-2501
  • department: means the department of insurance and financial institutions. See Arizona Laws 20-101
  • Health care insurer: means a disability insurer, group disability insurer, blanket disability insurer, health care services organization, hospital service corporation, prepaid dental plan organization, medical service corporation, dental service corporation or optometric service corporation or a hospital, medical, dental and optometric service corporation. See Arizona Laws 20-2501
  • Process: means a citation, writ or summons issued in the course of judicial proceedings. See Arizona Laws 1-215
  • Provider: means the physician or other licensed practitioner identified to the utilization review agent as having primary responsibility for providing care, treatment and services rendered to a patient. See Arizona Laws 20-2501
  • Service: means a diagnostic or therapeutic medical or health care service, benefit or treatment. See Arizona Laws 20-2501
  • United States: includes the District of Columbia and the territories. See Arizona Laws 1-215
  • Utilization review: means a system for reviewing the appropriate and efficient allocation of inpatient hospital resources, inpatient medical services and outpatient surgery services that are being given or are proposed to be given to a patient, and of any medical, surgical and health care services or claims for services that may be covered by a health care insurer depending on determinable contingencies, including without limitation outpatient services, in-office consultations with medical specialists, specialized diagnostic testing, mental health services, emergency care and inpatient and outpatient hospital services. See Arizona Laws 20-2501
  • Utilization review agent: means a person or entity that performs utilization review. See Arizona Laws 20-2501

B. Each utilization review agent and each health care insurer operating in this state whose utilization review system includes the power to affect the direct or indirect denial of requested medical or health care services or claims for medical or health care services shall adopt written utilization review standards and criteria and processes for the review, reconsideration and appeal of denials that do all of the following:

1. Meet the requirements of this article.

2. Are consistent with chapter 1 of this title.

3. Comply with section 20-2505, paragraphs 2 through 6.

C. This article does not apply to utilization review:

1. Performed under contract with the federal government for utilization review of patients eligible for all services under title XVIII of the social security act.

2. Performed by a self-insured or self-funded employee benefit plan or a multiemployer employee benefit plan created in accordance with and pursuant to 29 United States Code § 186(c) if the regulation of that plan is preempted by section 514(b) of the employee retirement income security act of 1974 (29 United States Code § 1144(b)), but this article does apply to a health care insurer that provides coverage for services as part of an employee benefit plan.

3. Of work related injuries and illnesses covered under the workers’ compensation laws in title 23.

4. Performed under the terms of a policy that pays benefits based on the health status of the insured and does not reimburse the cost of or provide covered services.

5. Performed under the terms of a long-term care insurance policy as defined in section 20-1691.

6. Performed under the terms of a medicare supplement policy as defined by the department.

D. This article does not create any new private right or cause of action for or on behalf of any member. This article provides only an administrative process for a member to pursue an external independent review of a denial for a covered service or claim for a covered service.

E. Utilization review activities involving retrospective claims review are limited to the provisions of this article only as clearly and specifically provided in the provisions of this article.

F. The processes available under this article do not apply to a denial of a nonformulary exception request that was appealed pursuant to 45 C.F.R. § 156.122(c). A provider or enrollee may appeal a denial of a nonformulary exception for a plan covered by 45 C.F.R. § 156.122(c) through the process prescribed in the federal rule.

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