I got a surprise bill. Can I submit a request for arbitration?
The following are tips to consider if you receive a surprise bill.
- Call your health insurance company if you need help determining the part of the bill that they will be paying and for help in determining whether you are eligible for the dispute resolution (arbitration) process. The arbitration process set forth in Arizona law DOES NOT apply to:
- Health care service the enrollee received before January 1, 2019;
- A health care service provided more than a year before the enrollee submits a request for arbitration (extended by any time the bill was the subject of a health care appeal);
- A bill from a single health care provider that is less than $1,000 after deducting the enrollee's copay, coinsurance, and deductible. A hospital bill may contain charges from several healthcare providers as well as from the hospital itself. The $1,000 threshold is NOT based on the sum of charges from multiple healthcare providers, but only on the amount that each healthcare provider has charged.
- A health care service that was not provided from a hospital, outpatient surgical center, laboratory, diagnostic imaging center or urgent care center that has a contract with the health insurer ("network facility").
- A health care service you received from someone other than a licensed, registered or certified as a health care professional under Arizona Revised Statutes Title 32, or a laboratory or a durable medical equipment provider that provided services in a network facility and separately bills the patient for the services.
- Enrollees covered by health care services organizations (a.k.a. HMOs). Under an HMO plan, an enrollee is often not required to pay any amount other than cost-sharing (copayment, coinsurance and deductible), If you are an HMO member, contact the HMO if you receive a bill for something other than copayment, coinsurance and deductible from a health care provider.
- Enrollees or their dependents who are covered under a federal employee health benefits plan [5 U.S.C. § 8902(m)(1)], whether the enrollee is an employee or retiree of the federal government.
- Limited benefit coverage;
- Health and accident coverage for state employees and their dependents;
- Self-funded or self-insured employee benefit plans preempted by the Employee Retirement Income Security Act of 1974 (a.k.a. ERISA) - your insurance card may show "ASO" or "Administrative Services Only" if you are covered under a self-funded plan;
- Health plans that exclude out-of-network coverage unless otherwise required by law;
- Federal Employee Health Benefit (FEHB) plans;
- Health care services that the insurer denied or that are otherwise not covered by the health plan;
- Provider or health facility charges that an individual agreed to directly pay rather than using the health plan;
- Provider or health facility charges for which the enrollee signed a disclosure notice on which the enrollee was provided information required by Arizona law, thereby resulting in the enrollee waiving rights to arbitration if the amount of the provider's bill was no greater than the estimated total cost that the provider included on the disclosure notice;
- A health care service that is the subject of a health care appeal that has not been decided;
- A health care bill or health care service for which the enrollee instituted a lawsuit or other legal action against the health insurer or healthcare provider;
- A health care bill that was previously settled or decided through the dispute resolution (arbitration) process.
- Call the healthcare provider that sent the bill and discuss your concerns. In most cases, Arizona law requires providers to provide an itemized bill on request, so review the charges carefully. Some providers might accept a lower payment. You can compare the amount you were charged to the average market price using websites like NewChoicehealth.com, and FairHealthConsumer.org.
- Submit a request for arbitration to the Arizona Department of Insurance if you believe the bill you received is eligible for arbitration.
We are aware of a phishing scam targeting insurance professionals claiming that the National Association of Insurance Commissioners received a complaint that the professional submitted a falsified claim. This fraudulent email displays the NAIC and CIPR logos, can originate from what appears to be an naic.org or gmail.com email account, and instructs the recipient to click on a link to download the complaint notification.
Certain antivirus products will detect this as a malicious email. If you receive a similar email and have any concerns, contact the NAIC Service Desk at (816) 783-8500 or he[email protected].