A. Any member who is denied a request for a covered service may pursue an expedited medical review of that denial if the member’s treating provider certifies in writing and provides supporting documentation to the utilization review agent that the time period for the informal reconsideration process and formal appeal process prescribed in sections 20-2535 and 20-2536 is likely to cause a significant negative change in the member’s medical condition at issue that is subject to the appeal. The treating provider’s certification is not challengeable by the health care insurer. A health care insurer whose utilization review activities consist only of claims review for services already provided is not required to provide its members an expedited medical review or expedited appeal pursuant to this section.  A health care insurer who conducts utilization review of claims in connection with services already provided is not required to provide its members an expedited medical review or expedited appeal of a claim related to a service already provided.

Terms Used In Arizona Laws 20-2534

  • Adverse decision: means a utilization review determination by the utilization review agent that a requested service or claim for service is not a covered service or is not medically necessary under the plan if that determination results in a documented denial or nonpayment of the service or claim. See Arizona Laws 20-2501
  • 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.
  • Claim: means a request for payment for a service already provided. See Arizona Laws 20-2501
  • Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
  • 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
  • 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
  • including: means not limited to and is not a term of exclusion. See Arizona Laws 1-215
  • 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
  • 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
  • Utilization review plan: means a summary description of the utilization review guidelines, protocols, procedures and written standards and criteria of a utilization review agent. See Arizona Laws 20-2501
  • Writing: includes printing. See Arizona Laws 1-215

B. On receipt of the certification and supporting documentation, the utilization review agent has one business day to make a decision and mail to the member and the member’s treating provider a notice of that decision, including the criteria used and the clinical reasons for that decision and any references to supporting documentation.  If the member’s complaint is an issue of medical necessity under the coverage document and not whether the service is covered, before making a decision, the agent shall consult with a physician or other health care professional who is licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 17, 19 or 29 or an out of state provider, physician or other health care professional who is licensed in another state and who is not licensed in this state and who typically manages the medical condition under review.

C. If the utilization review agent affirms the denial of the requested service, the agent shall telephonically provide and mail to the member and the member’s treating provider a notice of the adverse decision and of the member’s option to immediately proceed to an expedited appeal pursuant to subsection E of this section.

D. At any time during the expedited appeal process, the utilization review agent may request an expedited external independent review process pursuant to section 20-2537.  If the utilization review agent initiates the expedited external independent review process, the utilization review agent does not have to comply with subsection E of this section.

E. If the member chooses to proceed with an expedited appeal, the member’s treating provider shall immediately submit a written appeal of the denial of the service to the utilization review agent and provide the utilization review agent with any additional material justification or documentation to support the member’s request for the service.  Within three business days after receiving the request for an expedited appeal, the utilization review agent shall provide notice of the expedited appeal decision as prescribed in this subsection.  If the member’s complaint is an issue of medical necessity under the coverage document and not whether the service is covered, any provider, physician or other health care professional who is licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an out of state provider, physician or other health care professional who is licensed in another state and who is not licensed in this state, who is employed or under contract with the utilization review agent and who is qualified in a similar scope of practice as a provider, physician or other health care professional who is licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an out of state provider, physician or other health care professional who is licensed in another state and who is not licensed in this state and who typically manages the medical condition under appeal shall review the expedited appeal and render a decision based on the utilization review plan adopted by the utilization review agent.  Pursuant to the requirements of this subsection, the utilization review agent shall select the provider, physician or other health care professional who shall review the appeal and render the decision.  If the utilization review agent, provider, physician or other health care professional denies the expedited appeal, the utilization review agent shall telephonically provide and mail to the member and the member’s treating provider a notice of the denial and of the member’s option to immediately proceed to the external independent review prescribed in section 20-2537.

F. If the utilization review agent, provider, physician or other health care professional concludes that the covered service should be provided, the health care insurer is bound by the utilization review agent’s decision.