Health Care Appeals
Arizona Department of Insurance
2910 North 44
th
Street, Suite 210, Phoenix, Arizona 85018-7269
Phone: (602) 364-2399 | Fax: (602) 364-2398
Web: https://insurance.az.gov
STATE OF ARIZONA HEALTH CARE APPEALS TRANSMITTAL FORM
FOR INSURER USE ONLY
1. Are you requesting an Expedited External Independent Review?
Yes No
2. Was the denial based on: lack of medical necessity? a coverage issue?
3. Attach legible copies of A through G. For medical necessity cases, attach 2 copies.
A. Copy of the insured’s complete policy, certificate, evidence of coverage or similar document
B. All medical records and supporting documentation used to render the decision
C. Summary description of the applicable issues
D. A statement of the utilization review agent’s or insurer’s decision
E. The utilization review agent’s or insurer’s criteria used and the clinical reasons for the decision
F. The relevant portions of the utilization review agent’s utilization review plan
G. The insured’s or provider’s letter or appeal form requesting the appeal, and all pertinent
correspondence between the member/enrollee and the insurer
4. Insured Member’s Information: Name ____________________________________________
Patient’s name Under 18?
Mailing Address ________________________________________________________________
City State _____ Zip Code ______________
Telephone # _____ Member I.D. # ________________________________
5. Member’s coverage is:
Group Individual
HMO PPO POS
Self Funded Fully Insured
6. Insurer’s Information: Company Name ____________________________________________
Insurer’s NAIC #
Insurer’s Street Address __________________________________________________________
City _____________________________________________ State _____ Zip Code _________
Telephone # _____ Fax # _____________________________________
Contact Person Name Phone # __________________
Contact Person Email ____________________________________________________________
7. Treating Provider: (List multiple providers on second page)
Name _____________________________________________ Specialty _________________
Mailing Address ________________________________________________________________
City State _______ Zip Code ____________
Provider’s Telephone # _____ Fax # ___
8. External Review requested by: insured member insurer UR agent Provider
Date external review requested Date of level 2 decision __________________
9. Decision to deny or not authorize service or claims was made by:
Insurance Company HMO UR Agent
10. Completed by________________________________ ________________________ _______
Print Name & Title Signature Date
Form P-1098 Rev.03/2015
click to sign
signature
click to edit
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