§ 20-2530 Definitions
§ 20-2531 Applicability; requirements
§ 20-2532 Utilization review standards and criteria; requirements
§ 20-2533 Denial; levels of review; disclosure; additional time after service by mail; review process
§ 20-2534 Expedited medical review; expedited appeal
§ 20-2535 Informal reconsideration
§ 20-2536 Formal appeal
§ 20-2537 External independent review; expedited external independent review
§ 20-2538 Independent review organizations
§ 20-2539 Rules
§ 20-2540 Health care appeals fund
§ 20-2541 Health care insurer fee

Terms Used In Arizona Laws > Title 20 > Chapter 15 > Article 2

  • Action: includes any matter or proceeding in a court, civil or criminal. See Arizona Laws 1-215
  • Adult: means a person who has attained eighteen years of age. See Arizona Laws 1-215
  • 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.
  • 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 a person with 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
  • 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
  • Department: means the department of insurance. See Arizona Laws 20-2501
  • Director: means the director of the department of insurance. See Arizona Laws 20-2501
  • Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
  • Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
  • 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
  • Indirect denial: means a failure to communicate authorization or nonauthorization to the member by the utilization review agent within ten business days after the utilization review agent receives the request for a covered service. See Arizona Laws 20-2501
  • Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
  • Person: includes a corporation, company, partnership, firm, association or society, as well as a natural person. See Arizona Laws 1-215
  • Power of attorney: A written instrument which authorizes one person to act as another's agent or attorney. The power of attorney may be for a definite, specific act, or it may be general in nature. The terms of the written power of attorney may specify when it will expire. If not, the power of attorney usually expires when the person granting it dies. Source: OCC
  • 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
  • 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