Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.31
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyArizona Complete Health Dispute Update | OpenPayer
    Ask Trek AI about this page
    CurrentArizona Complete HealthPolicy AZ.AG.02

    Provider Claim Disputes

    Customize your policy alerts

    Sign up for Arizona Complete Health Policy AZ.AG.02 alerts

    Get alerted when Policy AZ.AG.02 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This policy establishes the process Arizona Complete Health staff and providers must use to initiate, review, investigate, resolve, document, and appeal provider claim disputes. It applies to directors, officers, employees, contracted providers, subcontracted providers, and noncontracted providers associated with Arizona health plans.

    Policy Summary
    PayerArizona Complete Health
    PolicyProvider Claim Disputes
    Policy CodePolicy N/A
    Change TypeAdministrative clarificationno material clinical or coverage change
    Effective Date01/30/2013
    Last ReviewDec 19, 2022
    Next Review DateN/A
    Key ActionProviders must submit a written claim dispute stating the factual and legal basis and requested relief.
    SourceLink
    POLICY UPDATE CHANGES

    The policy was revised to clarify the definition and use of the Provider Claim Dispute acronym and to update administrative procedures and references.

    The policy was updated to revise dispute, hearing-request, and hearing-forwarding timeframes and to update required information maintained in the provider claim dispute log.

    The policy was updated in December 2022 to revise required elements of the provider claim dispute log.

    The office responsible for handling forwarded hearing requests was renamed from the Office of Administrative Legal Services to the Office of the General Counsel.

    12 months or 60 daysClaim dispute filing deadline
    5 business days

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Dispute acknowledgment
    30 daysWritten decision deadline
    15 business daysReprocessing after overturned decision
    5 yearsRecord retention

    Provider Claim Dispute Handling Pathway

    Dispute and Processing Timeframes

    Remittance Advice Timing
    RequirementProvide remittance advice no later than 45 days after receipt of a claim.
    Applies toAll contracted and noncontracted providers.
    Required noticeThe remittance advice must address payment, denial, or recoupment of payment on a claim, in whole or in part.
    Claim Payment Dispute Deadline
    Payment disputeThe dispute must be received no later than 12 months from the ending date of service, 12 months after the date of eligibility posting, or within 60 days after payment, denial, or recoupment of a timely claim submission, whichever is later.
    Applicable eventsPayment, nonpayment, underpayment, overpayment, or recoupment of payment on a claim.
    Receipt requirementThe dispute must be received by the health plan within the applicable filing period.
    Sanction Dispute Deadline
    DeadlineThe dispute must be received within 60 days from the date of receipt of the notice advising that a sanction will be imposed.
    TriggerReceipt of the sanction notice.
    Dispute typeA dispute challenging the imposition of a sanction.
    Dispute Acknowledgment
    Acknowledgment deadlineWithin 5 business days of receipt of an appropriately managed dispute.
    Responsible partyThe Grievance Specialist sends the written acknowledgment.
    Acknowledgment contentThe acknowledgment states that the claim dispute has been received, will be reviewed, and that a decision will be issued within 30 days of receipt.
    Decision Deadline
    Decision deadlineWithin 30 days of the health plan's receipt of the dispute.
    Decision formatThe health plan issues a written, dated Notice of Decision.
    RecipientThe Notice of Decision is mailed to the disputing provider at its identified place of business.
    Overturned Claim Implementation
    Payment deadlineWithin 15 business days of the decision when claim processing is overturned.
    Required actionReprocess and pay the claim or claims in a manner consistent with the decision.
    DocumentationMaintain documentation in the claim dispute case file of timely reprocessing and payment.
    Record Retention
    Retention periodRetain provider claim dispute records for a minimum of five years after the final decision.
    StorageAll provider claim dispute records are filed in secured locations.
    Record scopeThe health plan maintains a log of all provider claim disputes initiated pursuant to the policy.
    Provider Claim Dispute Acknowledgment
    Acknowledgment deadlineWithin 5 business days of receipt of an appropriately managed provider claim dispute.
    Notice typeWritten acknowledgment that the claim dispute has been received and will be reviewed.
    Related decision periodThe acknowledgment states that a decision will be issued within 30 days of receipt of the claim dispute.
    Notice of Decision
    Notice deadlineWithin 30 days of the health plan's receipt of the claim dispute.
    Notice formatThe health plan issues a written, dated Notice of Decision.
    DeliveryThe notice is mailed to the disputing provider at its identified place of business.
    Decision-Timeframe Extension
    Consent requirementAn extension of the 30-day decision timeframe requires the consent of the parties.
    Timing requirementThe extension must be obtained before expiration of the original 30-day timeframe.
    Documentation requirementThe Grievance Specialist must document in the file the means and manner by which approval was obtained from the provider and the Grievance System Administrator.
    Administrative Hearing Request
    Hearing request deadlineThe written request must be received by the health plan within 30 calendar days of receipt of the health plan's decision.
    No decision renderedIf no decision was rendered, the request must be received within 30 days of the date of filing the claim dispute, absent an extension of time.
    Request formatThe request for a state fair hearing must be filed in writing.
    Hearing Request Forwarding
    Forwarding deadlineForward the request for hearing and supporting documents to the Office of the General Counsel within 5 business days of receipt.
    ConditionForwarding is required when the matter is not resolved.
    Applicable procedureThe health plan follows AHCCCS Contractor's Operations Manual Policy 445 for submission of hearing requests.
    Claim Reprocessing and Payment
    Reprocessing deadlineReprocess and pay the affected claim or claims within 15 business days of the decision.
    ApplicabilityThis applies when a dispute or appeal decision overturns claim processing in full or in part.
    ExceptionA different timeframe applies when one is specified.

    Provider Claim Dispute Requirements

    Note

    Provider Claim Dispute Policy Distribution

    Arizona Complete Health provides the Provider Claim Dispute (PCD) policy to subcontracted and noncontracted providers at specified points in the contracting and claim-payment process.

    • To all subcontractors at the time of contract and when a decision is made to impose a sanction.
    • To all contracted and noncontracted providers, through the remittance advice, when payment, denial, or recoupment occurs on a claim in whole or in part, no later than 45 days after receipt of the claim for payment.
    Billing Rule

    Claim Dispute Filing Deadline

    A dispute concerning payment, nonpayment, underpayment, overpayment, or recoupment of payment on a claim must be received by the health plan by the latest of the applicable deadlines below.

    Key Terms

    Definition
    TermClaim Dispute
    DefinitionA dispute involving a payment of a claim, denial of a claim, or imposition of a sanction.
    ScopeThe definition includes disputes involving claim payment, claim denial, or sanctions.
    Definition
    TermDay
    DefinitionA calendar day unless otherwise specified.
    Default calculationCalendar-day timing applies unless the policy specifies otherwise.
    Policy Summary
    PayerArizona Complete Health
    PolicyProvider Claim Disputes
    Policy CodePolicy N/A
    Change TypeAdministrative clarificationno material clinical or coverage change
    Effective Date01/30/2013
    Last ReviewDec 19, 2022
    Next Review DateN/A
    Key ActionProviders must submit a written claim dispute stating the factual and legal basis and requested relief.
    SourceLink
    On This Page
    Provider Claim Dispute Handling PathwayDispute and Processing TimeframesProvider Claim Dispute RequirementsKey Terms
    • Within 12 months after the ending date of service;
    • Within 12 months after the date of eligibility posting; or
    • Within 60 days after payment, denial, or recoupment of a timely claim submission.
    Billing Rule

    Sanction Dispute Filing Deadline

    A dispute challenging imposition of a sanction must be received within 60 days after the provider receives the notice advising that the sanction will be imposed.

    • The deadline runs from the date of receipt of the sanction notice.
    Documentation Required

    Required Dispute Submission

    Initiate a Provider Claim Dispute by sending a written statement to the health plan. The submission must explain the factual and legal basis for the dispute and state the relief requested; a dispute may be denied if its factual or legal basis is not provided.

    • Delivery methods: fax, e-mail, or regular mail.
    • Use the mailing address published in the Provider Manual and on Explanations of Payment (EOPs).
    Note

    Jurisdictional Routing

    The health plan initially reviews each Provider Claim Dispute to determine whether it is the appropriate entity to manage the matter. Some disputes are managed by AHCCCS Administration.

    • If the health plan is not responsible, it immediately forwards the dispute to the responsible health plan or AHCCCS with an explanation.
    • The health plan sends the filing party a copy of the transmittal.
    Billing Rule

    Acknowledgment and Decision Timeline

    For a dispute appropriately managed by the health plan, written acknowledgment must be sent within 5 business days of receipt, confirming receipt and review and stating that a decision will be issued within 30 days of receipt.

    • Within 30 days of receipt, the health plan mails a written, dated Notice of Decision to the provider's identified place of business.
    • The notice describes the nature of the dispute, issues involved, decision and supporting reasons, applicable authorities, hearing rights, informal settlement conference rights, and any overturned-claim payment action.
    Billing Rule

    Overturned Dispute Implementation

    When a claim dispute is overturned, the health plan reprocesses and pays the affected claim or claims in a manner consistent with the decision within 15 business days of the decision date.

    • The claim dispute case file must document timely reprocessing and payment.
    Documentation Required

    Decision-Period Extension

    The 30-day period for issuing a decision may be extended only with the consent of the parties. Consent must be obtained before the original decision period expires.

    • The Grievance Specialist must document in the file the means and manner by which approval for the extension was obtained from the provider and the Grievance System Administrator.
    Billing Rule

    Calendar-Day Computation

    When a period is measured in calendar days, begin counting on the day after the triggering act, event, or decision and include all calendar days through the final day.

    • If the final day falls on a weekend or legal holiday, the period extends through the end of the next day that is neither a weekend nor a legal holiday.
    Note

    Request a Hearing After a Claim Dispute Decision

    If dissatisfied with the health plan's decision, the provider may request a state fair hearing by submitting a written request that is received by the health plan within 30 calendar days after the provider receives the decision.

    • If the health plan upholds the denial and a hearing request is filed, the health plan reviews the matter to determine whether it can be resolved without a hearing.
    • If unresolved, the health plan forwards the hearing request and supporting documents to the Office of the General Counsel within 5 business days and follows AHCCCS Contractor's Operations Manual Policy 445.
    Note

    Request a Hearing When No Decision Is Issued

    If no written Notice of Decision is received within 30 days after the claim dispute is filed, and no extension was approved, the provider may request a state fair hearing in writing.

    • The request must be received by the health plan within 30 days after the date the claim dispute was filed.
    • The same hearing-request routing and review requirements apply if the matter is not resolved.
    Documentation Required

    Document and Communicate Claim Dispute Decisions

    The written, dated Notice of Decision is mailed to the disputing provider's identified place of business and documents the health plan's determination.

    • Required information includes the nature of the dispute; issues involved; decision and reasons; references to applicable statutes, rules, contracts, policies, and procedures; the right to request a hearing; the right to request an informal settlement conference; and, when applicable, the 15-business-day reprocessing and payment commitment.
    Billing Rule

    Reprocess Overturned Claims

    If the appeal process reverses the health plan's decision in full or in part, the health plan reprocesses and pays the claim or claims, with interest when applicable, within 15 business days after the decision date unless a different timeframe is specified.

    • Interest is paid as outlined in AHCCCS Contractor Operations Manual Section 203.
    Documentation Required

    Obtain and Document Decision-Timeframe Extensions

    Any extension of the 30-day decision timeframe requires advance consent of the parties and must be approved before the original timeframe expires.

    • The Grievance Specialist must record in the case file how and by whom the provider and Grievance System Administrator approved the extension.
    • The file must document the extension approval and preserve the basis for the revised decision timeframe.
    Definition
    TermFiled
    DefinitionThe date on which the claim dispute is received by the health plan.
    TriggerReceipt of the claim dispute by the health plan establishes the filed date.