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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.

Corrected Claims
Please review instructions outlined in Provider Resources > Claims and Payment

Step 1: Submit Reconsideration Request
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 below. Our address for submitting a claim dispute 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, you 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.

A claim dispute must be submitted 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 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 below. 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.

For additional information regarding the Provider Claim Dispute process please refer to the Provider Operations Manual.