Provider Claim Disputes
The provider claim dispute process affords providers the opportunity to challenge a decision by Arizona Complete Health that impacts the provider related to:
- Payment or nonpayment of a claim;
- The recoupment of payment on a claim; and
- The imposition of sanctions.
Many times, disagreements between a provider and Arizona Complete Health can be resolved through an informal process. Providers are encouraged to try and resolve issues informally before initiating the formal provider claim dispute process. However, providers should be aware that a formal provider claim dispute must be initiated within the following timeframes:
- 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.
- For challenges to sanctions, within 60 days of the date of notice advising that a sanction will be imposed.
It is important for providers to ensure the claim dispute is submitted in writing and contains all required information and is 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 initiated by writing to us at:
Arizona Complete Health
Attention: Grievance and Appeals – Provider Claim Disputes
1870 W. Rio Salado Parkway
Tempe, AZ 85281
For additional information regarding the Provider Claim Dispute process please refer to the Provider Operations Manual.