I got a surprise bill. Can I submit a request for arbitration?

NEW AGENCY


Arizona Department of Insurance
100 North 15th Avenue, Suite 261

Phoenix, AZ  85007-2630


Starting July 1, 2020, we became the
Department of Insurance and Financial Institutions (DIFI).


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. 
sort descending
Arizona's Surprise Bill Resolution Report for 2019

As shown in the attached report prepared pursuant to A.R.S. § 20-3118(A), the Department of Insurance received 91 requests for dispute resolution in Calendar Year 2019.  Of those, 53 have been resolved or closed, and health plan enrollees saved $41,538 by submitting their surprise bills for resolution.  

Not all health care bills qualify for the surprise bill resolution process.  The Department's Suprise Out-of-network Billing Dispute Resolution website (https://insurance.az.gov/soonbdr, and especially the section entitled, "I got a surprise bill. Can I submit a request for arbitration?") lists conditions when a health care bill may not qualify under Arizona law for the dispute resolution process.  But for those that do, the enrollee will only be responsible for paying the enrollee's cost-sharing amounts (copay, coinsurance and deductible) if the enrollee provides information the Department needs, and participates in an informal settlement teleconference with the health care insurer and the health care provider.

Form SOONBDRFI-I: Request for Information - Insurer

Surprise Out-of-Network Billing Dispute Request for Information (SOONBDRFI) form that a health insurer will need to be complete and return with attachments in response to a Department of Insurance request for information concerning a surprise out-of-network billing dispute resolution (SOONBDR) request.

Form SOONBDRFI-P: Request for Information - Healthcare Provider

Surprise Out-of-Network Billing Dispute Request for Information (SOONBDRFI) form that a healthcare provider will need to be complete and return with attachments in response to a Department of Insurance request for information concerning a surprise out-of-network billing dispute resolution (SOONBDR) request.

Form SOONBDRIST: Informal Settlement Teleconference Outcome

The health insurer involved in a surprise out-of-network dispute will complete this form after a scheduled informal settlement teleconference ("IST") is held.  The insurer is responsible for reporting the outcome of the IST.

Form SOONBDRR: Surprise Out-of-Network Billing Dispute Resolution Request

BEFORE COMPLETING THIS FORM: Review information on the Department's website (https://insurance.az.gov/soonbdr) and confer with your health insurer to determine whether your healthcare bill qualifies as a surprise bill that is eligible for the dispute resolution process.  

SOONBDRA: Arbitration Decision

The arbitrator that conducts the arbitration proceeding for a surprise-out-of-network dispute will complete this form to notify the Department of the outcome of the arbitration.