Arizona's fourth level: an independent physician, at no cost

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

Arizona names and sequences the whole thing in statute, which makes it unusually easy to tell where a case actually stands. There are four levels, and external review is the last of them:

• Level 1 — Expedited Medical Review, for cases that cannot wait.
• Level 2 — Informal Reconsideration by the plan.
• Level 3 — Formal Appeal, still inside the plan.
• Level 4 — External Independent Review: an independent physician, selected by DIFI, whose decision binds the plan.
• It covers medical-necessity and experimental or investigational denials once the internal levels are done.

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.

The reviewer Arizona puts on the case

Arizona is specific about who decides. The Department selects the independent review organization from those under state contract, and the reviewer must be a physician who typically manages the condition at issue, with no conflict of interest in the case. The plan has no say in the choice, which removes the most common objection to an external decision before it can be raised.

Prior authorization: posted rules, and one form

Arizona has pushed the front end of utilization management into the open. Under A.R.S. §§ 20-3401 and 20-3403, and § 20-3406 added by HB 2621, insurers and the utilization-review agents acting for them must publish their prior-authorization requirements online, and must accept the DIFI-approved uniform prior-authorization request form — approved by January 1, 2022, with provider use required from January 1, 2023. A denial that rests on a criterion the payer never published is worth naming as such.

Step therapy: the four grounds for an override

Arizona's 2021 step-therapy law (SB 1270) requires every plan to run an exception process and sets out when an override must be granted:

• The required drug is contraindicated for this patient.
• It is expected to be ineffective given what is known about the patient's condition.
• The patient already failed the required drug — or another in the same class.
• The required drug is otherwise not in the patient's best interest.