Arizona Medicaid Appeals and Fair Hearings

If your Arizona Medicaid was denied, cut, or terminated, you have the right to appeal and request a fair hearing, and you can often keep your benefits while the appeal is decided.1 In Arizona, Medicaid is run by the Arizona Health Care Cost Containment System (AHCCCS), and most members get their care through a contracted health plan, so the path to a hearing usually runs through that plan first.2

In This Guide

• What you can appeal in Arizona Medicaid
• The Arizona Medicaid appeal deadlines that decide your case
• How to keep your benefits during an Arizona Medicaid appeal
• Managed care (MCO) appeals: exhaust your health plan first
• How to request an Arizona Medicaid fair hearing
• Frequently Asked Questions

What you can appeal in Arizona Medicaid

Federal law guarantees every Medicaid applicant and member the right to a fair hearing before the state agency. Section 1902(a)(3) of the Social Security Act requires each state plan to give a hearing to anyone whose claim for medical assistance is denied or is not acted on with reasonable promptness, and the implementing regulation at 42 CFR 431.220 extends that right to anyone who believes the agency acted erroneously or made an adverse determination.1

In practice, that means you can appeal an "action" your health plan or AHCCCS takes against your care. An action is a denial, a reduction, a suspension, or a termination of a service or benefit, or a failure to act on a request in a timely manner.2 The most common items members bring to appeal are:

• An application or eligibility denial
• A termination or reduction of a covered service, such as a cut in personal care hours
• A prior authorization denial or a change in your level of care
• A denial of payment, or the plan's failure to act within required timeframes

The right reaches across the program, including members in the Arizona Long Term Care System (ALTCS), the Medicaid long-term-care program that covers most elderly and physically disabled members receiving nursing-home or home-based care.2

The Arizona Medicaid appeal deadlines that decide your case

An Arizona Medicaid appeal is governed by its deadlines, and they are not all the same number.

The request window: up to 90 days

Under 42 CFR 431.221(d), the agency must allow a reasonable time, not to exceed 90 days from the date the notice of action is mailed, to request a fair hearing.2 Arizona implements that federal right, and the AHCCCS grievance-and-appeals materials do not state a hearing-request window shorter than that 90-day maximum, so read the deadline printed on your own notice and do not wait past it.2

The continuation window: before the action takes effect

This is the earlier, tighter deadline, and it is the one that keeps your benefits flowing. It is covered in the next section.

The managed care windows: 60 days, then 90 to 120 days

If your denial came from a health plan, you have 60 calendar days from the date on the adverse benefit determination notice to file the plan's internal appeal.3 After the plan resolves that appeal against you, the state must give you no fewer than 90 and no more than 120 calendar days from the date of the plan's notice of resolution to request a State Fair Hearing; the exact number within that band is set by the state.4

One more deadline protects renewals. If your coverage was terminated only because you did not return a renewal form or requested information on time, you do not always have to reapply: under 42 CFR 435.916, if you submit the form or missing information within 90 days after the termination date, the agency must reconsider your eligibility without a new application.5

How to keep your benefits during an Arizona Medicaid appeal

Keeping your benefits during an appeal is called aid paid pending. It is not automatic: you have to request it, and you have to request it in time.

The Arizona rule

Your appeal must be filed before the day the reduction, suspension, or termination is to take effect. Where there are fewer than 10 days between the notice date and the effective date on the notice, your request to continue services must be filed within 10 days from the notice date.2

The federal rule behind it

Under 42 CFR 431.230(a), if the agency sent the required advance notice and you request the hearing before the date of action, it may not terminate or reduce your services until a decision is rendered after the hearing, unless the only issue is one of law or policy.6 The trigger is the date of action on your notice, not a flat count of days after you receive it.

If you continue benefits and lose

If your benefits continue and the action is later upheld at the hearing, you may have to pay for the services you received during the appeal.2 Federal law permits the agency to recoup the cost of services furnished solely because benefits were continued.6

The practical takeaway: when an adverse-action notice arrives, find the effective date on it, file your appeal before that date, and put your request to continue benefits in writing.

Managed care (MCO) appeals: exhaust your health plan first

Most Arizona Medicaid members, including elderly and physically disabled members in ALTCS, get their care through a contracted managed care organization (MCO), which is the health plan that manages your benefits. When the plan takes an action you disagree with, you appeal to the plan before you can reach a State Fair Hearing.2 These rules come from the federal managed care regulations at 42 CFR Part 438.

Who your plan is

For the ALTCS Elderly and/or Physically Disabled (EPD) program, which covers most Brevy readers arranging Medicaid long-term care in Arizona, AHCCCS extended its existing contracts with UnitedHealthcare Community Plan, Banner-University Family Care, and Mercy Care from October 1, 2025 through September 30, 2026.2 Your specific plan and its Grievance and Appeals contact are listed in the member handbook the plan gives you. You can reach the ALTCS Member Services line at 1-888-621-6880.2

What counts as a plan action

Under 42 CFR 438.404, the plan must give you timely, written notice of an adverse benefit determination, which includes a denial or limited authorization of a service, a reduction or termination of a previously authorized service, a denial of payment, or a failure to act within required timeframes. That notice must tell you how to appeal, how to request an expedited appeal, and how to ask that your benefits continue during the appeal.7

The internal appeal and exhaustion

You have 60 calendar days from the date on the determination notice to file the plan's internal appeal, and the appeal may be requested orally or in writing.3 A plan has only one level of appeal, and you must exhaust it before requesting a State Fair Hearing.4 Contact the plan's Grievance and Appeals Department, or call the customer service line on your member ID card, to file.2

How fast the plan must decide

For a standard appeal, the plan must resolve it within 30 calendar days; for an expedited appeal, within 72 hours. Either timeframe may be extended by up to 14 calendar days if you request the extension or the plan shows the state that more information is needed and the delay is in your interest.8 In Arizona, an expedited appeal, resolved within three working days absent an extension, is available when waiting the standard time for a decision would put your health in serious jeopardy.2

After the plan upholds its denial

Once the plan issues an unfavorable appeal decision, you may request a State Fair Hearing, which is a hearing where your appeal is presented before an administrative law judge (ALJ).2 If the plan fails to meet the notice and timing rules, the appeal is deemed exhausted and you may go straight to a State Fair Hearing.7

How to request an Arizona Medicaid fair hearing

Filing with the wrong office is a common, avoidable delay. Where your request goes depends on who acted and why.

All appeals must be in writing.2 Match your situation to one of these three paths:

A written request for a State Fair Hearing on a service denial is filed with the AHCCCS Office of the General Counsel at Arizona Health Care Cost Containment System Administration, 150 N. 18th Ave., MD-15013, Phoenix, AZ 85007. The fax number is 602-253-9115, and you can reach the office by phone at 602-417-4232 within Maricopa County or 1-800-654-8713 ext. 74232 statewide.2 At the hearing, an administrative law judge takes evidence from you and the plan or agency and issues a decision on your appeal.2

Learn More

Find personalized help navigating an Arizona Medicaid appeal at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.