{"data":{"id":"us-az/a.r.s.-20-2804","jurisdiction":"us-az","citation":"A.R.S. § 20-2804","heading":"Utilization review; medically necessary emergency services","body":"A. A health care services plan engaging in utilization review to determine whether any emergency services rendered by a provider were medically necessary and in accordance with this chapter shall consider the following factors:\n\n1. Current emergency medical literature and standards of care.\n\n2. Clinical information reasonably available to the provider at the time of the services.\n\nB. A health care services plan shall not deny a claim for emergency services on the basis that the services were not medically necessary without review by a physician of the plan's choosing.\n\nC. For the purpose of claims payment and utilization review of emergency services, a health care services plan shall have the right to require as a condition of payment that each treating provider produce all of the following:\n\n1. Copies of all medical records pertaining to the emergency services provided to the enrollee.\n\n2. Copies of records pertaining to any prior authorization and specialty consultation requests made by the provider.\n\n3. A detailed and itemized billing statement.\n\nD. If a health care services plan pays any portion of a provider's claim for services rendered to an enrollee, the plan shall not be permitted to recover all or part of that payment from the enrollee, except for:\n\n1. The cost of an initial medical screening examination and related charges where the examination determined that emergency services were not medically necessary.\n\n2. Payments made as a result of misrepresentation, fraud or clerical error.\n\n3. Copayment, coinsurance or deductible amounts that are the responsibility of the enrollee.","path":["Title 20 Insurance"],"source_url":"https://www.azleg.gov/ars/20/02804.htm","current_through":"57th Legislature, 2nd Regular Session (effective 2027-01-01); mirror section count 24991","vintage":"2026-09-15","retrieved_at":"2026-10-26T05:51:13Z","sha256":"c9c934b54769551bc9ca7c3a00f0960d554d429d49b3e78246d952679d5a0481","source_id":"us-az","stale":false,"prev":"us-az/a.r.s.-20-2803","next":"us-az/a.r.s.-20-281"},"notice":"GroundRules: Original legal text. Not legal advice."}