External review in Arizona: the External Independent Review

Arizona's four-level appeal — and where external review sits

Arizona structures the whole process as four levels: an expedited medical review, an informal reconsideration, a formal appeal, and finally the External Independent Review. That last level is where an independent physician — one who typically manages the condition at issue and has no conflict of interest — takes over, and the decision binds the plan.

• Covers medical-necessity and experimental/investigational denials after the internal levels.
• DIFI selects the independent review organization; the plan doesn't choose it.
• The reviewer is a physician who typically treats the condition under review.
• The decision binds the plan — an overturn means the plan must cover the service.

The four-month deadline

You generally have four months after your insurer notifies you in writing that your formal appeal was denied to request the External Independent Review. You submit the request to the insurer, which then has five business days to forward it and the file to DIFI.

How to file

1. 1

   Work through the internal levels

   Complete the plan's internal appeal levels (expedited review, reconsideration, formal appeal) first — the External Independent Review follows them.

2. 2

   Submit the request to your insurer

   Use the insurer's DIFI-approved appeal packet; the insurer forwards your request and records to the Department.

3. 3

   DIFI selects the reviewer

   The Department assigns an independent review organization under state contract — a physician who manages the condition, with no conflict of interest.

4. 4

   Receive the binding decision

   The reviewer decides on the record; DIFI notifies the parties, and the decision binds the plan.

How fast — and it's free

• Standard: DIFI selects the reviewer within 5 days; the reviewer decides within 21 days; the Department notifies the parties within 5 business days (a good-cause extension of up to 10 days is possible).
• Expedited: the reviewer is selected within 2 business days and decides within 72 hours.
• There is no fee for any level of the appeal, including external review.
• The decision is binding on the plan.

For Arizona providers and billers

Arizona has tightened the front end of utilization management, which helps set up a clean appeal. The state requires payers to publish their prior-authorization requirements and to accept DIFI-approved uniform PA request forms, and a 2021 step-therapy law (SB 1270) created a mandatory exception process with defined override criteria — contraindication, expected ineffectiveness, prior failure of the required drug, or a treatment not in the patient's best interest.