Utilization Review Licensing in Arizona

Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in Arizona. For assistance with licensing, please contact us to learn about our software and managed license services.

Arizona Utilization Review Agent Registration

Type of Review:

Medical Utilization Review

Agency:Arizona Department of Insurance
Law:

AZ Stat. § 20-2501 et seq.

Foreign Qualification is Prerequisite:Yes
Notes:

Registration is required for agents that perform utilization review for fully insured commercial business. Agents that only conduct reviews for government coverage (Medicare or Medicaid) are not required to register. Additionally, URAC accredited agents and other agents described in AZ Stat. § 20-2502 are exempt from registration requirements.

Initial Registration

Agency Fee:

$0

Notarize:Required
Notes:

Contact the Life and Health Division at 602-364-2393 for application forms.

Required Attachments:
  • A certificate of good standing from the Arizona Corporation Commission.
  • A copy of a national UR accreditation certificate (URAC, NCQA or AAGC) if applicable.
  • A utilization review plan that includes a summary description of review guidelines, protocols and procedures, standards and criteria to be used in evaluating inpatient hospital care, inpatient medical care, outpatient surgical care and any medical, surgical and health care services that may be covered by a health care insurer and the provisions by which patients, providers or hospitals may seek reconsideration or appeal of decisions made by the utilization review agent.
  • A list of all contracts (if any) the entity has with a health care insurer or third party administrator to conduct utilization review for fully insured commercial plans in Arizona.
  • A copy of the materials or a description of the procedure designed to inform patients and providers, as appropriate, of the requirements of the utilization review plan.

Registration Renewal

Agency Fee:

$0

Due:

Triennially by the anniversary of certification.

Supplemental Reporting
Annual Attestation

Filing Method:

Email to UtilizationReview@azinsurance.gov.

Agency Fee:

$0

Due:

Annually by March 1. Attestations may be filed as early as January 1.

Notarize:Required
Notes:

Contact the department for an attestation form.

Required Attachments:
  • If there have been material changes to the UR Plan or appeals process, submit the updated information in redline format. If there have been no changes provide a statement to that effect.
  • Provide the name, phone number and email address of three company contacts including the Medical Director and the UR or QI Director/Manager
  • Attach a copy of your current URAC, NCQA and/or AAAHC Certificate(s) of Accreditation.

Arizona Resources

Annual Report Apostille - Authentication Architecture Firm License Articles of Incorporation Articles of Organization Business License Certificate of Authority Certificate of Cancellation Service Certificate of Good Standing / Existence Certificate of Merger Certification - Authentication Change Your Registered Agent Charitable Gaming License
Charitable Gift Annuity Licensing Compliance Charitable Registration Construction License Converting Your Entity Corporation LLC Nonprofit Amendment DBA Dissolve Corporation LLC Nonprofit Employer (Payroll & Withholding Tax) Registration Service Employment Agency Licensing Energy Licensing Engineering Firm License Entity Name Reservation Fictitious Name Registration & Renewal
Foreign Corporation Foreign LLC Healthcare and Pharmaceutical Licenses How to File Articles of Incorporation How to Form an LLC How to Incorporate How to Start a Nonprofit Organization Insurance Licensing Licensing Resources Moving Your Company's Domicile to Nonprofit Articles of Incorporation Nonprofit Compliance Obtain Certified Copies
Private Investigator License Real Estate Licensing Registered Agent ( Statutory Agent) Reinstate Corporation LLC Nonprofit Sales & Use Tax Registration Service Sales Tax Exemption Start a Business Tax Clearance Certificate Tax Exemption Utilization Review Certification / License

Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.

Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.

External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.

Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.

Prospective Review - Utilization review that occurs prior to treatment.

Retrospective Review - Utilization review that occurs after treatment and often after payment.

Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.

Utilization Review Agent (URA) - An entity that conducts utilization review.

Utilization Review Plan - A document of the procedures used during utilization review.

Revised October 29, 2021. Complete data last reviewed February 04, 2021.
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