Appealing an AHCCCS Denial

The Arizona Health Care Cost Containment System (AHCCCS) is the medical coverage for qualified residents of Arizona.  The coverage gives certain people access to doctors,  physical exams and immunizations. This coverage also allows an individual to receive hospital care and get prescriptions. However, in some instances coverage is refused. When this is the case, it’s helpful to have knowledge of appealing an AHCCS denial.

AHCCCS Claim Denied due to Missing Documentation

In some circumstances, the AHCCCS  sends a letter informing you they need more information in order to give approval for Available AHCCCS Health Plans. They’ll not be able to make a decision on your application without specific information. Once they receive the missing information you will be informed of the final decision. When the initial request is denied due to missing documentation or other items, it can be sent back with the necessary documents and  reviewed for a final decision.

Resubmission after Denial

Once an applicant receives an AHCCCS denial due to missing documents or information, they can resubmit the denied request back. To do this they must send back updated or additional documentation. The resubmission will also have:

  • The corrected claim
  • Necessary additional documentation,
  • A cover letter with the word “resubmission” typed or written on it
  • The copy of the denial sent from AHCCCS.

Reconsideration after Denial

A reconsideration is just a bit different than a resubmission. It needs to include a copy of the original claim, documentation necessary to complete the application, a cover letter with the word “reconsideration” typed or written on it, and a copy of the denial sent from AHCCCS. You must also include a description of any correction.

Continued AHCCCS Service or Benefits Denial

After the AHCCCS receives a resubmission or reconsideration, they still may deny benefits or health care assistance. An AHCCS denial can also include suspension of benefits, a denial of surgery or for a wheelchair. When this happens, it is time to do an appeal. An appeal is your request to reconsider or change the decision to deny service or services. You need to make an appeal orally or in writing to whichever agency made the determination. It is either the DES or the AHCCCS. The health plan member handbook should contain detailed instructions on filing an appeal. An appeal must be filed prior to the day the termination, suspension or reduction of services is to take effect. This means that if you are noticed that service will stop in 10 days, the appeal must be filed in less than 10 days.

AHCCCS Appeal Process

An expedited appeal would be necessary if the member’s health would be in jeopardy by waiting 30 days for a decision from AHCCCS. This would entail the patient potentially suffering harm to life or health. The doctor would make the decision as to whether the appeal should be expedited. When it is expedited, the appeal should be resolved within three working days.

Denial of an Appeal

When you have done an appeal and the result is still a denial of service, you will need to request a Fair Hearing. The Notice of Appeal Resolution you receive from AHCCCS will explain why service was denied and will also tell you how to ask for a Fair Hearing.

If you’re interested in learning more about appealing an AHCCS denial, setting up a consultation with Chelle Law or learning more about our services for Arizona residents, contact us today.