The proposed bill, if enacted, would amend current statutes by adding a new requirement for the review process of claim denials or adverse appeal determinations related to behavioral health services covered by the American Indian Health Program (AIHP). Specifically, it would mandate that before any claim denial or adverse determination based on medical necessity occurs, the claim and supporting medical documentation must be reviewed and approved by an individual with at least two years of relevant clinical experience providing similar services. This change aims to ensure that decisions regarding the medical necessity of services are made by qualified professionals.

Additionally, the bill would expand the scope of review to include any claim denial or adverse appeal determination, rather than limiting it to specific appeals. This broader application is intended to enhance the oversight of claims related to behavioral health services within the AIHP, thereby improving the quality and accountability of the review process. The new provisions would be inserted into title 36, chapter 29, article 1 of the Arizona Revised Statutes, specifically adding section 36-2903.18.

Statutes affected:
Introduced Version: 36-2903.18
Senate Engrossed Version: 36-2903.18