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Medicaid Claim Resolution Process Update - July 2025

Date: 07/08/25

Medicaid Provider Claim Resolution Process  

The Medicaid provider claim resolution process allows providers the opportunity to challenge a decision by Arizona Complete Health related to payment or nonpayment of a claim or recoupment of a claim payment.

We’ve recently enhanced our web page www.azcompletehealth.com > For Providers > Provider Resources > Grievance and Appeal System > Medicaid Provider Claim Resolution Process to include details on the informal reconsideration process, and updated instructions for submitting a corrected claim, an informal reconsideration and a formal claim dispute via our secure provider portal.

STEP 1: INFORMAL RECONSIDERATION Disagreements frequently can be resolved through our informal “Reconsideration” process. We encourage providers to attempt to resolve issues informally before initiating the formal provider claim dispute process.

A “Reconsideration” is a request for review of a claim that a provider believes was incorrectly paid or denied or for which submission of medical records is needed to further process or review the claim.

  • A reconsideration is an informal review performed by the claims department
  • We recommend utilizing the reconsideration option first before filing a formal claim dispute
  • You may submit a reconsideration if you disagree with the payment or denial or need to submit medical records for claims which require medical record review
  • You should NOT use this option if a prior authorization was not obtained

When filing a reconsideration, please include the following information:

  • A copy of the original claim
  • Cover letter with “RECONSIDERATION” written or typed
  • A copy of the remittance advice on which the claim was denied or incorrectly paid
  • Any additional documentation needed to demonstrate the need for reprocessing
  • A brief note describing what correction is needed. If you do not provide a written justification as to why a legitimately denied claim deserves reconsideration, it will be difficult for us to reverse our original decision.

Reconsiderations may be submitted via our secure provider portal (preferred method) or by mail. A link to instructions for submitting via the portal is located on the Medicaid Provider Claim Resolution Process web page. Our address for submitting a claim reconsideration by mail is:

Arizona Complete Health
Attention: Claims Department Reconsiderations
PO Box 9010
Farmington, MO 63640

Reconsiderations may be submitted within 12 months of the date of service. Reconsiderations are reviewed within 60 days of receipt.  If the claim is overturned, you will receive an updated remittance advice. If the original processing is upheld, and the reconsideration was submitted by mail, you will receive a determination letter outlining the decision. If you submit the reconsideration via the secure portal, the portal will reflect the upheld decision.

STEP 2: FORMAL CLAIM DISPUTE If an informal reconsideration submission is not successful, providers may submit a formal claim dispute to challenge a payment or denial of a claim. The request for a claim dispute should indicate the facts and the relief requested.

Requirements for Filing a Claim Dispute

A formal provider claim dispute must be initiated within the timeframe outlined below.

For challenges relating to the payment, denial or recoupment of a claim, the later of the following:

  • 12 months after the date of delivery of the service
  • 12 months after the date of eligibility posting or
  • 60 days after the payment or denial of a timely claim submission, or the recoupment of payment.

Providers must submit the claim dispute in writing. The claim dispute submission must contain all required information and be filed within the required timeframes. Failure to do so will result in the denial of the claim dispute. A notice of claim dispute must specify the statement of the factual and legal basis for the claim dispute and the relief requested. Claim disputes may be denied if the filing party has failed to provide a comprehensive factual or legal basis for the dispute.

A claim dispute may be submitted via our secure provider portal (preferred method) or by mail. A link to instructions for submitting via the portal is located on the Medicaid Provider Claim Resolution Process web page. Our address for submitting a claim dispute by mail is:

Arizona Complete Health
Attention:  Grievance and Appeals – Provider Claim Disputes
1850 W. Rio Salado Parkway, Suite 211
Tempe, AZ 85281

After a claim dispute review is completed a Notice of Decision will be issued.  If the Notice of Decision is unfavorable, the provider has 30 days from receipt of the notice to request a state fair hearing.

We encourage you to attempt to resolve disagreements informally before initiating the formal dispute process and to use the secure provider portal to submit your request.

If you have questions, please contact your Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us: AzCHProviderEngagement@azcompletehealth.com.