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  • Appeal Form For Ahcccs/altcs Service Denials

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Member Request to File an AHCCCS/ALTCS Appeal AHCCCS/ALTCS Member Information: Member Name: Address: City, State, Zip AHCCCS ID #: Date of Birth: Phone: Information about Person Filing Appeal (if.

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Initial Claim: 6 months from the date of service (If HCP is primary, the claim timeliness changes to 7-months from the date of service or eligibility date). Corrected Claim: 12 months from the date of service.

Grievance: Concerns that do not involve an initial determination (i.e. Accessibility/Timeliness of appointments, Quality of Service, MA Staff, etc.) Appeal: Written disputes or concerns about initial determinations; primarily concerns related to denial of services or payment for services.

Providers must understand The Health Plan grievance system in order to assist members who wish to utilize a grievance system process....Specifically, The Health Plan adheres to the following grievance resolution process: Acknowledgement. ... Communication and Information. ... Resolution. ... Decision making.

Just call our Customer Contact Center, Monday through Friday from 7 a.m. to 6 p.m. at 1-888-926-5057 (TTY 711 for the hearing impaired). You may also fax a written appeal to the Ambetter from Arizona Complete Health Appeals and Grievances Department at 1-877-615-773.

Coordination of benefits—Federal regulation and state laws require that AHCCCS pay for medical benefits only after other responsible parties have first paid their share, making AHCCCS the payor of last resort. This process is called coordination of benefits.

Requirements for Filing a Claim Dispute Within twelve months after the date that eligibility is posted or. Within sixty days after the date of the denial of a timely claim submission, whichever is later.

You may contact the State Protection and Advocacy System, the Arizona Center for Disability Law 1-800-922-1447 in Tucson and 1-800- 927-2260 in Phoenix. You may also contact the Office of Human Rights at (602) 364-4585, or 1-800-421-2124 for assistance.

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.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232