Welcome health insurers!

This portal is for insurance companies to transmit health care appeals.

Submission Requirements

Make sure to include:

• Transmittal Form

  The State of Arizona Health Care Appeals Transmittal Form (available from https://insurance.az.gov/insurers/life-health-forms-rates-compliance/health-care-appeals) completed by the insurer.

• Provider Certification Form

  Provider certification form (available from https://insurance.az.gov/insurers/life-health-forms-rates-compliance/health-care-appeals) for an expedited medical review.

• Request for Appeal

  The member’s or provider’s letter or form requesting the appeal.

• Insurer Decision

  The utilization review agent’s or insurer’s decision, including a summary of applicable issues, relevant portions from the utilization review plan, and the criteria used and the clinical reasons for the claim decision.

• Policy/Contract

  A copy of the insured’s complete policy, certificate, evidence of coverage or similar document.

• Medical Records

  Medical records and supporting documentation used to render the claim decision.

• Appeal Correspondence

  Correspondence between the member/provider and the insurer involving the claim.

File Requirements

Files must be in one of the following formats: Word (doc or docx), Excel (xls or xlsx), Adobe Acrobat (pdf), or one of the following graphic formats: jpg, jpeg, gif, tiff, png, or bmp. Do not combine files into a single ZIP file – this portal will allow you to upload multiple files at the same time.

Uploading Instructions

1. Enter your NAIC number and click [Search]. Make sure the system displays the correct insurance company name for the filing you are submitting.
2. Enter your contact information and the claimant information.
3. Click the [+ Select Files] button. On the “File Upload” screen, you can drag and drop files from a directory on your computer/network or you can click the [Navigate to files] button, which will open a file explorer window that you can use to locate and select files to be uploaded. You can upload more than one file at a time. Files you selected to upload will be listed under the [+ Select Files] button.
4. For each file, select the “Document Type” from the dropdown list.
5. After entering information for all documents, click the [Submit] button.
6. The system will present you a “Success!” report, which you should print and retain as documentation of your filing submission.