Arizona Department of Insurance

Health Care Appeals Portal

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.

Contact information for this filing


Member information for this filing


Additional information for this filing


Documents


Cannot submit the page until a valid NAIC/License number has been entered!