reglab/statecodes huggingface dataset:
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2214 - Member participation in writings, expenses, servicing allowance, management fees and losses

20-2214.
Member participation in writings,  expenses,  servicing allowance,  management fees and losses
All members of the association shall participate in its writings,  expenses,  servicing allowance,  management fees and losses in the proportion that the net direct premium of each member,  excluding that portion of a premium attributable to the operation of the association,  written during the preceding calendar year bears to the aggregate net direct premium written in this state by all members of the association. Each member's participation in the association shall be determined annually on the basis of the net direct premium written during the preceding calendar year.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2215 - Appeal by applicants to the association; order

20-2215.
Appeal by applicants to the association;  order
Any applicant to the association or any person insured pursuant to this chapter,  or their representatives,  or any affected member may appeal to the director within thirty days after any ruling,  action or decision by or on behalf of the association,  with respect to those items defined by the directors of the association and approved by the director as appealable matters. Except as provided in section 41-1092.08,  subsection H,  all final orders of the director made pursuant to this section are subject to judicial review pursuant to title 12,  chapter 7,  article 6,  except that notwithstanding any other law,  proceedings for judicial review act as a stay of the enforcement of any order or decision of the director disapproving or ordering the withdrawal,  adjustment or termination of the effectiveness of any rate filing made by or on behalf of the association on the ground that the rates or premiums for the business of the association are unreasonable or excessive. The association may continue to charge rates pursuant to the filing pending final order of the court.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2216 - Annual filing; contents

20-2216.
Annual filing;  contents
Annually on or before January 1,  the association shall file in the office of the director a statement which contains information with respect to its transactions,  condition,  operations and affairs during the preceding year. Such statement shall contain such matters and information as are prescribed and shall be in such form as is approved by the director. The director,  at any time,  may require the association to furnish additional information with respect to its transactions,  condition or any matter connected with its transactions and condition considered to be material and of assistance in evaluating the scope,  operation and experience of the association.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2219 - Liability of the association

20-2219.
Liability of the association
There is no liability on the part of nor does any cause of action accrue against the association or its members,  the director or his authorized representatives or any other person or organization for any acts or omissions made in good faith by them during any proceeding or concerning any matters within the scope of this chapter. The association is a legal entity separate and distinct from its members.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2302 - Scope of article

20-2302.
Scope of article
A. This article applies to any health benefits plan that provides coverage to eligible employees or dependents in this state and that is issued by an accountable health plan if:
1. Any portion of the premium or benefits is paid by or on behalf of the employer.
2. The eligible employee or dependent is reimbursed by or on behalf of the employer for any portion of the premium.
3. The health benefits plan is treated by the employer or any of the eligible employees or dependents as part of a plan or program for the purposes of section 106,  162 or 220 of the internal revenue code.
B. This article applies to a health benefits plan that qualifies as a group health plan under section 2791(a)(1) of the health insurance portability and accountability act of 1996 (P.L. 104-191;  110 Stat. 1936).
C. This article does not apply to any policy that is issued on an individual basis.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2303 - Approval as accountable health plan; definition

20-2303.
Approval as accountable health plan;  definition
An entity may offer,  issue or otherwise provide a health benefits plan only if the entity is authorized to transact insurance in this state and is approved as an accountable health plan by the director based on a determination that the entity meets the applicable requirements of this chapter.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2306 - Use of uniform employee health status questionnaire

20-2306.
Use of uniform employee health status questionnaire
A. An accountable health plan shall use the uniform employee health status questionnaire prescribed by the department for all small groups for which the accountable health plan requires employees and their covered dependents to complete health status questionnaires.
B. An accountable health plan may add to the questionnaire additional questions that pertain to eligibility for coverage and for underwriting purposes and may ask the producer or the employees and dependents follow-up questions about their responses to the uniform employee health status questionnaire.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2307 - Eligibility; annual open enrollment period

20-2307.
Eligibility;  annual open enrollment period
A. Except as otherwise provided in this section or section 20-2308 or 20-2309,  an accountable health plan may not exclude from coverage any employee or a spouse or a dependent child of the employee if the person meets the eligibility requirements established by the employer.
B. Subsection A of this section does not apply to a period in which an employee is excluded from coverage under the health benefits plan pursuant to an employer requirement that imposes a minimum period of service before the employee and the employee's dependents are eligible for coverage.
C. An accountable health plan may deny enrollment to employees or family members of an employer if the employees or family members are located outside the service area of the accountable health plan and if the denial is applied uniformly without regard to health status-related factors or insurability.
D. An accountable health plan that provides an annual open enrollment period of at least thirty-one days may deny enrollment to a late enrollee until the next annual open enrollment period or may require acceptable evidence of insurability.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2308 - Portability

20-2308.
Portability
A newborn child,  adopted child or child placed for adoption is an eligible individual if the child was timely enrolled and otherwise would have met the definition of an eligible individual as prescribed in section 20-1379 other than the required period of creditable coverage and the child is-not subject to any preexisting condition exclusion or limitation if the child has been continuously covered under health insurance coverage or a health benefits plan offered by an accountable health plan since birth,  adoption or placement for adoption.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2313 - Marketing practices

20-2313.
Marketing practices
A. An accountable health plan or its insurance producer shall not:
1. Discourage an employer from filing an application for a health benefits plan because of the health status-related factors,  industry,  occupation or geographic location of the employer.
2. Encourage or direct an employer to seek a health benefits plan from another insurer because of the health status-related factors,  industry,  occupation or geographic location of the employer.
B. This section does not prohibit an accountable health plan from providing information regarding the geographic service area of the accountable health plan.
C. Notwithstanding any law to the contrary,  an accountable health plan may market health benefits plans to groups of small employers from the same or different industries that elect to pool their risks on a voluntary basis.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2325 - Diabetes; equipment; supplies

20-2325.
Diabetes;  equipment;  supplies
A. Any health benefits plan that is offered by an accountable health plan and that provides coverage for diabetes shall also provide coverage for equipment and supplies that are medically necessary and that are prescribed by a health care provider,  including:
1. Blood glucose monitors.
2. Blood glucose monitors for the legally blind.
3. Test strips for glucose monitors and visual reading and urine testing strips.
4. Insulin preparations and glucagon.
5. Insulin cartridges.
6. Drawing up devices and monitors for the visually impaired.
7. Injection aids.
8. Insulin cartridges for the legally blind.
9. Syringes and lancets including automatic lancing devices.
10. Prescribed oral agents for controlling blood sugar that are included on the plan formulary.
11. To the extent coverage is required under medicare,  podiatric appliances for prevention of complications associated with diabetes.
12. Any other device,  medication,  equipment or supply for which coverage is required under medicare from and after January 1,  1999. The coverage required in this paragraph is effective six months after the coverage is required under medicare.
B. Nothing in subsection A of this section:
1. Entitles a member or enrollee of an accountable health plan to equipment or supplies for the treatment of diabetes that are not medically necessary as determined by the accountable health plan's medical director or the medical director's designee.
2. Provides coverage for diabetic supplies obtained by a member or enrollee of an accountable health plan without a prescription unless otherwise permitted pursuant to the terms of the health benefits plan.
3. Prohibits an accountable health plan from imposing deductibles,  coinsurance or other cost sharing in relation to benefits for equipment or supplies for the treatment of diabetes.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2331 - Accountable health plans; varying copayments and deductibles allowed

20-2331.
Accountable health plans;  varying copayments and deductibles allowed
A. Except as provided in sections 20-1379 and 20-2304,  an accountable health plan may offer one or more health benefits plans that contain a choice of deductibles,  coinsurance,  copayments,  out-of-pocket and any other cost sharing levels. Plans offered under this section shall clearly disclose in marketing materials,  certificates of coverage and contracts the insured s financial responsibilities. An accountable health plan that offers such a health benefit plan shall continue to provide any mandated health coverage that is required by this state or by federal law.
B. This section does not prohibit a health benefits plan that is intended to qualify as a high deductible health plan as defined by 26 United States Code section 223(c)(2) from requiring the application of deductibles,  copayments or coinsurance to benefits provided under the health benefits plan.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2332 - Eosinophilic gastrointestinal disorder; formula

20-2332.
Eosinophilic gastrointestinal disorder;  formula
A. Any health benefit plan that is offered by an accountable health plan and that contains a prescription drug benefit shall cover amino acid-based formula that is ordered by a physician or by a registered nurse practitioner if:
1. The insured has been diagnosed with an eosinophilic gastrointestinal disorder.
2. The insured is under the continuous supervision of a physician who is licensed pursuant to title 32,  chapter 13 or 17 or a registered nurse practitioner who is licensed pursuant to title 32,  chapter 15.
3. There is risk of a mental or physical impairment without the use of the formula.
B. An accountable health plan shall cover at least seventy-five per cent of the cost of the formula. The accountable health plan may limit the maximum annual benefit for formula under this section to twenty thousand dollars.
C. This section does not apply to limited benefit coverage as defined in section 20-1137.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2341 - Uninsured small business health insurance plans; mandatory coverage exemption; definitions

20-2341.
Uninsured small business health insurance plans;  mandatory coverage exemption;  definitions
A. A policy,  subscription contract,  contract,  plan or evidence of coverage issued to an uninsured small business by a health care insurer is not subject to the requirements of any of the following:
1. Section 20-461,  subsection A,  paragraph 17 and subsection B.
2. Section 20-826,  subsection C,  paragraph 1.
3. Section 20-826,  subsections F,  J,  K,  U,  V,  W,  X and Y.
4. Sections 20-841,  20-841.01,  20-841.02,  20-841.03,  20-841.04,  20-841.06,  20-841.07 and 20-841.08.
5. Section 20-841.05,  subsections B and E.
6. Section 20-1057,  subsections C,  K,  L,  Y,  Z,  AA and BB.
7. Sections 20-1057.01,  20-1057.03,  20-1057.04,  20-1057.05 and 20-1057.08.
8. Section 20-1057.02,  subsection B.
9. Section 20-1342,  subsection A,  paragraph 8,  subdivision (a).
10. Section 20-1342,  subsection A,  paragraphs 11 and 12.
11. Section 20-1342,  subsections H,  I,  J and K.
12. Section 20-1342.01.
13. Sections 20-1376,  20-1376.01,  20-1376.02,  20-1376.03 and 20-1376.04.
14. Section 20-1402,  subsection A,  paragraph 4,  subdivision (a).
15. Section 20-1402,  subsection A,  paragraphs 7 and 8.
16. Section 20-1402,  subsections H,  I,  J,  K and L.
17. Section 20-1404,  subsection F,  paragraph 1.
18. Section 20-1404,  subsections I,  Q,  R,  S,  T and U.
19. Section 20-1406.
20. Sections 20-1406.01,  20-1406.02,  20-1406.03 and 20-1406.04.
21. Section 20-1407.
22. Section 20-2321.
23. Section 20-2327.
24. Section 20-2329.
B. Section 20-2304,  subsection B does not apply to a policy,  subscription contract,  contract,  plan or evidence of coverage issued to an uninsured small business pursuant to subsection A of this section.
C. In this article,  unless the context otherwise requires:
1. " Health care insurer"  means a disability insurer,  group disability insurer,  blanket disability insurer,  health care services organization,  hospital service corporation,  medical service corporation or hospital and medical service corporation.
2. " Uninsured small business"  means a small employer that did not provide a health benefits plan for at least ninety days immediately before the effective date of coverage provided pursuant to this section,  except that this requirement does not apply at the renewal of coverage pursuant to this section.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2404 - Compulsory associations

20-2404.
Compulsory associations
A. No risk retention group is required or permitted to join or contribute financially to any insurance insolvency guaranty fund,  or similar mechanism,  in this state,  and no risk retention group,  or its insureds or claimants against its insureds,  may receive any benefit from any fund for claims arising under the insurance policies issued by the risk retention group.
B. If a purchasing group obtains insurance covering its members' risks from an insurer that is not authorized in this state or a risk retention group,  no risks wherever resident or located may be covered by any insurance guaranty fund or similar mechanism in this state.
C. If a purchasing group obtains insurance covering its members' risks from an authorized insurer,  only risks resident or located in this state may be covered by the state guaranty fund.
D. A risk retention group shall participate in this state's joint underwriting associations and mandatory liability pools as provided by this title.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2406 - Purchasing groups; exemption from certain laws relating to the group purchase of insurance

20-2406.
Purchasing groups;  exemption from certain laws relating to the group purchase of insurance
A. A purchasing group which meets the criteria established under the federal liability risk retention act of 1986 is exempt from any law of this state relating to the creation of groups for the purchase of insurance,  prohibition of group purchasing or any law that would discriminate against a purchasing group or its members.
B. This state shall not enact any law or the director shall not adopt a rule which imposes prohibitions or requirements on purchasing groups in violation of section 3(a) of the liability risk retention act of 1986,  Public Law 99-563. A purchasing group is subject to all applicable laws of this state.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2407 - Notice and registration requirements of purchasing groups

20-2407.
Notice and registration requirements of purchasing groups
A. A purchasing group which intends to do business in this state,  before doing business,  shall furnish notice to the director which:
1. Identifies the state in which the group is domiciled.
2. Specifies the lines and classifications of liability insurance which the purchasing group intends to purchase.
3. Specify the method by which,  and the person or persons,  if any,  through whom,  insurance will be offered to its members whose risks are resident or located in this state.
4. Identifies the principal place of business of the group.
5. Provides other information as may be required by the director to verify that the purchasing group meets the criteria under section 20-2401,  paragraph 9.
B. The purchasing group shall register with and designate the director as its agent solely for the purpose of receiving service of legal documents of process. The director shall determine the filing fee. This requirement does not apply in the case of a purchasing group:
1. Which in any state both:
(a) Was domiciled before April 1,  1986.
(b) Is domiciled on October 27,  1986 in any state.
2. Which both:
(a) Before October 27,  1986 purchased insurance from an insurance carrier licensed in any state.
(b) Since October 27,  1986 purchased its insurance from an insurance carrier licensed in any state.
3. Which was a purchasing group under the requirements of the product liability risk retention act of 1981 (15 United States Code section 3901) before October 27,  1986.
4. Which does not purchase insurance that was not authorized for purposes of an exemption under the product liability risk retention act of 1981 (15 United States Code section 3901),  in effect before October 27,  1986.
C. Any purchasing group which was doing business in this state before the effective date of this chapter,  within thirty days after the effective date of this chapter,  shall furnish notice to the director pursuant to subsection A and furnish information required pursuant to subsection B.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2408 - Restrictions on insurance purchased by purchasing groups

20-2408.
Restrictions on insurance purchased by purchasing groups
A. A purchasing group may not purchase insurance from a risk retention group that is not chartered in a state or from an insurer which is not admitted in the state in which the purchasing group is located,  unless the purchase is effected through a licensed insurance producer.
B. No purchasing group may offer insurance policy coverage prohibited by this title or declared unlawful by the supreme court of this state.
C. A purchasing group which obtains liability insurance from an insurer that is not admitted in this state or a risk retention group shall inform each of the members of the group which have a risk resident or located in this state that the risk is not protected by an insurance insolvency guaranty fund in this state and that the risk retention group or the insurer may not be subject to all insurance laws and rules of this state.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2409 - Administrative and procedural authority regarding risk retention groups and purchasing groups

20-2409.
Administrative and procedural authority regarding risk retention groups and purchasing groups
The director may make use of any of the powers established under this title to enforce the laws of this state so long as those powers are not specifically preempted by the product liability risk retention act of 1981,  as amended by the risk retention amendments of 1986. This includes the director's administrative authority to investigate,  issue subpoenas,  conduct depositions and hearings,  issue orders and impose penalties. With regard to any investigation,  administrative proceedings or litigation,  the director may rely on the procedural law and rules of this state. The injunctive authority of the director in regard to risk retention groups is restricted by the requirement that any injunction be issued by a court of competent jurisdiction.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2411 - Duty of insurance producer to obtain license

20-2411.
Duty of insurance producer to obtain license
A. No person,  firm,  association or corporation may act or aid in any manner in soliciting,  negotiating or procuring liability insurance in this state from a risk retention group unless the person,  firm,  association or corporation is licensed as an insurance producer in accordance with this title.
B. No person,  firm,  association or corporation may act or aid in any manner in soliciting,  negotiating or procuring liability insurance in this state for a purchasing group or any of its members from an authorized insurer or a risk retention group chartered in a state unless the person,  firm,  association or corporation is licensed as an insurance producer in accordance with this title.
C. No person,  firm,  association or corporation may act or aid in any manner in soliciting,  negotiating or procuring liability insurance from an insurer that is not authorized to do business in this state on behalf of a purchasing group which is located in this state unless the person,  firm,  association or corporation is licensed as a surplus lines broker or excess line broker in accordance with this title.
D. For purposes of acting as an insurance producer or surplus lines broker for a risk retention group or purchasing group pursuant to subsections A,  B and C of this section,  the requirement of residence in this state does not apply.
E. Every person,  firm,  association or corporation that is licensed pursuant to this title,  on business placed with risk retention groups or written through a purchasing group,  shall inform each prospective insured of the provisions of the notice required by section 20-2403,  subsection G in the case of a risk retention group and section 20-2408,  subsection C in the case of a purchasing group.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2412 - Binding effect of orders issued in United States district court

20-2412.
Binding effect of orders issued in United States district court
An order issued by any district court of the United States enjoining a risk retention group from soliciting or selling insurance or operating in any state on a finding that such a group is in a hazardous financial condition is enforceable in the courts of this state.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2414 - Annual report

20-2414.
Annual report
A. Beginning on or before December 31,  2017,  the director shall annually report the following information to the president of the senate and the speaker of the house of representatives:
1. The number of risk retention groups licensed in this state since August 6,  2016.
2. Any regulatory action taken by the director against a risk retention group licensed in this state for noncompliance with section 20-2402.
3. The total number of private passenger automobile insurance policies:
(a) That were nonrenewed during the previous calendar year pursuant to sections 20-1631 and 20-1632.
(b) In force in this state as of the end of the previous calendar year.
(c) In force within this state's automobile assigned risk plan as of the end of the previous calendar year.
B. The director may provide the report required by subsection A of this section in an electronic format.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2502 - Utilization review activities; exemptions

20-2502.
Utilization review activities;  exemptions
A. A utilization review agent shall not conduct utilization review in this state unless the utilization review agent meets or is exempt from this article.
B. A person is exempt from sections 20-2504,  20-2505,  20-2506,  20-2507 and 20-2508 and section 20-2509,  subsection A if the person:
1. Is accredited by the utilization review accreditation commission,  the national committee for quality assurance or any other nationally recognized accreditation process recognized by the director.
2. Conducts internal utilization review for hospitals,  home health agencies,  clinics,  private offices or other health facilities or entities if the review does not result in the approval or denial of payment for hospital or medical services.
3. Conducts utilization review activities exclusively for work related injuries and illnesses covered under the workers' compensation laws in title 23.
4. Conducts utilization review activities exclusively for a self-funded or self-insured employee benefit plan if the regulation of that plan is preempted by section 514(b) of the employee retirement income security act of 1974 (29 United States Code section 1144(b)).
C. A utilization review agent shall conduct utilization review in accordance with the agent's utilization review plan that is on file with the department pursuant to section 20-2505 and in accordance with section 20-2532.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2503 - Utilization review standards; applicability; definition

20-2503.
Utilization review standards;  applicability;  definition
A. The utilization review standards established in this chapter apply to prospective,  concurrent and retrospective utilization review for:
1. Inpatient admissions to hospitals and other inpatient facilities.
2. Outpatient admissions to surgical facilities.
3. Outpatient surgical services provided in a health care provider's office.
4. Medical,  surgical and health care services that may be covered by a health care insurer depending on determinable contingencies,  including without limitation outpatient services,  in-office consultations with medical specialists,  specialized diagnostic testing,  mental health services,  emergency care and inpatient and outpatient hospital services.
B. For purposes of this section " inpatient admissions"  includes inpatient admissions to all acute medical,  surgical,  obstetrical,  psychiatric and chemical dependency inpatient services at a licensed hospital or other inpatient facility.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2504 - Utilization review agents; certification; rules

20-2504.
Utilization review agents;  certification;  rules
A. The director shall issue a certificate to a utilization review agent that meets all of the requirements of this chapter and all applicable rules. A utilization review agent shall submit a signed and notarized application on a form prescribed by the director.
B. A certificate is not transferable.
C. The director may adopt rules consistent with the requirements of this chapter.
D. Except as provided in section 20-2532,  information required by the department with respect to customers,  patients or utilization review plans is confidential and is not open to public inspection.
E. The utilization review agent shall pay all certification expenses as provided in section 20-2506.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2505 - Application for certification

20-2505.
Application for certification
A utilization review agent applying for a certificate shall submit the following information to the department:
1. A signed and notarized application on a form prescribed by the director.
2. 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.
3. The professional qualifications of the personnel either employed or under contract to perform the utilization review. Personnel conducting utilization review shall have current licenses that are in good standing and without restrictions from a state health care professional licensing agency in the United States and may be a member of a profession that practices inpatient hospital or outpatient surgical care.
4. A description of the policies and procedures that ensure that a representative of the utilization review agent is available to receive and send the notice and acknowledgments prescribed in article 2 of this chapter and is reasonably accessible to patients and providers in this state and the department by a toll free telephone line or by acceptance of long-distance collect calls for forty hours each week during normal business hours.
5. A description of the policies and procedures that ensure that the utilization review agent will follow applicable state and federal laws to protect the confidentiality of individual medical records.
6. 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.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2506 - Certification; responsibilities of department; cost recovery

20-2506.
Certification;  responsibilities of department;  cost recovery
A. The director shall examine the affairs,  transactions,  accounts and records of each utilization review agent before issuing an initial certificate and as often as the director deems it necessary in order to determine if a utilization review agent is in compliance with this chapter. The department shall not make any determination of quality of care,  appropriateness of utilization review recommendations or medical necessity relating to any plan of care or treatment.
B. All examination and examination related expenses shall be charged to the utilization review agent and shall be paid by the director out of the insurance examiners' revolving fund in accordance with section 20-159.
C. The director may use independent contract examiners pursuant to sections 20-148 and 20-149 to perform the examinations under this section.
D. Any expenses of examinations not paid by the utilization review agent within thirty days of the billing of the examination expenses shall be paid by the health care insurer that used the services or that contracted with the utilization review agent. If more than one health care insurer used the services of or contracted with a utilization review agent each health care insurer shall pay an equal share of the uncollected expenses.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2507 - Certificates; renewal

20-2507.
Certificates;  renewal
A. A certificate expires on the third anniversary of its effective date unless the certificate is renewed for a three year term as provided in this section.
B. A certificate holder may renew an unexpired certificate for an additional three year term if the certificate holder meets the requirements of this chapter.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2509 - Confidentiality

20-2509.
Confidentiality
A. A utilization review agent shall file with the director written procedures for assuring that patient information it obtains during the process of utilization review is maintained as confidential in accordance with applicable federal and state laws,  is used solely for the purposes of utilization review,  quality assurance,  discharge planning and catastrophic case management and is shared only with agencies authorized by the patient in writing and on a form prescribed by the director to receive the information. Summary data are not confidential if the data do not provide sufficient information to allow identification of individual patients. This subsection does not permit a person to obtain information without complying with other requirements of this title.
B. A utilization review agent shall comply with all applicable state and federal laws relating to the confidentiality of medical records.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2511 - Violation; injunctive relief

20-2511.
Violation;  injunctive relief
If the director believes that a utilization review agent is violating or is about to violate section 20-2502,  the director may order the agent to cease and desist. The director through the attorney general may file a complaint in the superior court in the county in which the agent transacts utilization review business to enjoin and restrain the agent from committing or continuing the violation. If the director orders the utilization review agent to cease and desist,  the agent may request a hearing pursuant to title 41,  chapter 6,  article 10 and,  except as provided in section 41-1092.08,  subsection H,  seek judicial review pursuant to title 12,  chapter 7,  article 6. If the director files a complaint through the attorney general the superior court has jurisdiction of the proceeding and may make and enter an order or judgment awarding preliminary or final relief as in its judgment is proper.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2530 - Definitions

20-2530.
Definitions
For the purposes of this article:
1. " Member"  means a person who is covered under a health care plan provided by a health care insurer or that person's treating provider,  parent,  legal guardian,  surrogate who is authorized to make health care decisions for that person by a power of attorney,  a court order or the provisions of section 36-3231,  or agent who is an adult and who has the authority to make health care treatment decisions for that person pursuant to a health care power of attorney.
2. " Utilization review agent"  means those persons and entities that perform utilization review as defined in section 20-2501 and includes any health care insurer whose utilization review plan includes the direct or indirect denial of requested medical or health care services or the denial of claims.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2531 - Applicability; requirements; exception

20-2531.
Applicability;  requirements;  exception
A. Notwithstanding article 1 of this chapter and subject to subsection B of this section,  this article applies to all utilization review decisions made by utilization review agents and health care insurers operating in this state.
B. Each utilization review agent and each health care insurer operating in this state whose utilization review system includes the power to affect the direct or indirect denial of requested medical or health care services or claims for medical or health care services shall adopt written utilization review standards and criteria and processes for the review,  reconsideration and appeal of denials that do all of the following:
1. Meet the requirements of this article.
2. Are consistent with chapter 1 of this title.
3. Comply with section 20-2505,  paragraphs 2 through 6.
C. This article does not apply to utilization review:
1. Performed under contract with the federal government for utilization review of patients eligible for all services under title XVIII of the social security act.
2. Performed by a self-insured or self-funded employee benefit plan or a multiemployer employee benefit plan created in accordance with and pursuant to 29 United States Code section 186(c) if the regulation of that plan is preempted by section 514(b) of the employee retirement income security act of 1974 (29 United States Code section 1144(b)),  but this article does apply to a health care insurer that provides coverage for services as part of an employee benefit plan.
3. Of work related injuries and illnesses covered under the workers' compensation laws in title 23.
4. Performed under the terms of a policy that pays benefits based on the health status of the insured and does not reimburse the cost of or provide covered services.
5. Performed under the terms of a long-term care insurance policy as defined in section 20-1691.
6. Performed under the terms of a medicare supplement policy as defined by the department.
D. This article does not create any new private right or cause of action for or on behalf of any member. This article provides only an administrative process for a member to pursue an external independent review of a denial for a covered service or claim for a covered service.
E. Utilization review activities involving retrospective claims review are limited to the provisions of this article only as clearly and specifically provided in the provisions of this article.
F. The processes available under this article do not apply to a denial of a nonformulary exception request that was appealed pursuant to 45 Code of Federal Regulations section 156.122(c). A provider or enrollee may appeal a denial of a nonformulary exception for a plan covered by 45 Code of Federal Regulations section 156.122(c) through the process prescribed in the federal rule.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2535 - Informal reconsideration

20-2535.
Informal reconsideration
A. Any member who is denied a service and who does not qualify for an expedited medical review pursuant to section 20-2534 may request,  either orally or in writing,  an informal reconsideration of that denial by notifying the person described in section 20-2533,  subsection C,  paragraph 3. After the denial,  the member has up to two years to request an informal reconsideration. A health care insurer whose utilization review consists only of claims review for services already provided is not required to provide its members an informal reconsideration pursuant to this section. A health care insurer who conducts utilization review of claims in connection with services already provided is not required to provide its members an informal reconsideration of a claim related to a service already provided.
B. The utilization review agent shall send a written acknowledgment to the member and the member's treating provider within five business days after the utilization review agent receives the request for informal reconsideration.
C. The utilization review agent may request any pertinent medical records pursuant to title 12,  chapter 13,  article 7.1 that are necessary for the informal reconsideration.
D. The utilization review agent has up to thirty days after receipt of the request for reconsideration to send to the member and the member's treating provider a notice of the utilization review agent's decision and the criteria used and the clinical reasons for that decision.
E. At any time during the informal reconsideration process,  the utilization review agent may submit a request to the director to initiate an external independent review process pursuant to section 20-2537. At the same time that the utilization review agent submits the request to the director,  the utilization review agent shall also render a written decision and shall send the written decision,  including the criteria used and the clinical reasons for that decision and any references to supporting documentation,  to the member,  the member's treating provider and the director.
F. If the utilization review agent does not submit a request to the director pursuant to subsection E of this section and at the conclusion of the informal reconsideration process the utilization review agent denies the covered service or the claim for the covered service,  the utilization review agent shall provide the member and the treating provider with a written statement of the agent's decision and the criteria used and the clinical reasons for that decision,  including any references to any supporting documentation and a notice of the option to proceed after the formal appeal process to an external independent review.
G. If the utilization review agent concludes that the covered service should be provided or the claim for a covered service should be paid,  the health care insurer is bound by the utilization review agent's decision.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2538 - Independent review organizations

20-2538.
Independent review organizations
A. Pursuant to title 41,  chapter 23,  the director shall procure as many independent review organizations as necessary and practicable to perform the independent medical reviews described in section 20-2537.
B. Through the procurement process the director shall ensure that any procured independent review organization uses physicians or other health care professionals who are licensed pursuant to title 32,  chapter 7,  8,  11,  13,  14,  17,  19,  19.1 or 29 or out of state physicians or other health care professionals who are licensed in another state and who are not licensed in this state,  who are board certified or board eligible by the appropriate American medical specialty board and who are in the same or a similar scope of practice as a physician or another health care professional who is licensed pursuant to title 32,  chapter 7,  8,  11,  13,  14,  17,  19,  19.1 or 29 or an out of state physician or another health care professional who is licensed in another state and who is not licensed in this state and who typically manages the medical condition,  procedure or treatment under review.
C. The independent review organization and its individual reviewer shall not have a substantial interest in the member,  provider or health care insurer involved in the particular case under review or any other conflict of interest that will preclude the reviewer from making a fair and impartial decision. The individual reviewer shall not be a policyholder or insured member of a company whose case is being reviewed.
D. An out of state physician or another health care professional who is licensed in another state and who is not licensed in this state in a field substantially similar to the laws of this state applicable to physicians or other health care professionals who are licensed under title 32,  chapter 7,  8,  11,  13,  14,  16,  17,  19,  19.1 or 29 and who are certified or board eligible by the appropriate American medical specialty board may serve as an independent reviewer for the procured independent review organization and that provider's analysis,  assessment or decision for the independent review organization does not constitute the practice of medicine or any other health care profession in this state.
E. The director,  any procured independent review organization or any independent reviewer acting in good faith is not liable for the analysis,  assessment or decision of any case reviewed pursuant to this article.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2540 - Health care appeals fund

20-2540.
Health care appeals fund
A. The health care appeals fund is established consisting of monies collected pursuant to subsection B of this section. The fund is a special state fund pursuant to section 35-142,  subsection A,  paragraph 8. Monies in the fund do not revert to the state general fund. The department shall administer the fund. Monies in the fund are continuously appropriated and are exempt from the provisions of section 35-190 relating to lapsing of appropriations.
B. The director shall charge an appealing member's health care insurer for all amounts owed to the independent review organization,  pursuant to subsection C of this section,  to decide the member's appeal. The director may assess each health care insurer for administrative costs for implementing and maintaining the external independent review process as prescribed in this section and section 20-2538. The director shall deposit all collected monies in the fund.
C. The director shall use monies in the fund to:
1. Compensate procured independent review organizations for performing independent medical reviews on a per case rate unless the director determines that another method is necessary to carry out the purposes of this article.
2. Perform the responsibilities relating to the procurement of independent review organizations and to implement and maintain the external independent review process.
D. An independent review organization shall submit to the director for approval a detailed invoice consistent with the method of payment prescribed in subsection C of this section.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2541 - Health care insurer fee

20-2541.
Health care insurer fee
The director may assess each health care insurer that is authorized to transact insurance:
1. A single fee of not more than $200 per insurer.
2. Up to $200 each year for the costs of performing the responsibilities relating to the procurement of independent review organizations as prescribed in sections 20-2537 and 20-2538 and for implementing and maintaining the external independent review process,  including processing and paying claims through the health care appeals fund established by section 20-2540. The department is authorized one full-time equivalent position to perform these responsibilities.
2023 Arizona Revised Statutes › Title 20 - Insurance › § 20-2603 - Reports

20-2603.
Reports
A. In addition to any other materials an insurer is required to submit to the director pursuant to this article,  an insurer authorized to transact variable life insurance business in this state shall submit the following to the director:
1. An annual statement of the business of its separate account or accounts in a form that the national association of insurance commissioners prescribes.
2. Before its use in this state,  any information that the insurer furnishes to applicants pursuant to section 20-2607.
3. Before its use in this state,  the form of the reports to policyholders that are prescribed by section 20-2609.
4. Any additional information concerning the insurer's variable life insurance operations or separate accounts as the director deems necessary.
B. The director shall disapprove any material that is submitted under this section that the director finds to be false,  misleading,  deceptive or inaccurate in any material respect. If the material was previously distributed,  the director shall require that the insurer distribute amended material.
C. The director may disapprove any material that is filed with the director if at any time the director finds that the material does not comply with the standards established pursuant to the laws of this state.