Surprise Out-of-network Bill Dispute Resolution

NEW ADDRESS


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

Phoenix, AZ  85007-2630


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


BEFORE SUBMITTING YOUR REQUEST FOR ARBITRATION USING THE ONLINE PORTAL:

STEP 1: Review information on this web page (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.  

STEP 2: Complete Form SOONBDRR (Surprise Out-of-Network Billing Dispute Resolution Request), and print and sign the form. 

STEP 3 (IMPORTANT!):  Scan and save to your computer:

  • The Form SOONBDRR that you completed and signed in STEP 2
  • Your insurance card, front and back
  • Correspondence (letters, memos, bills, etc.) between you, the provider, and the insurer relating to this bill
  • Other information that will help explain this matter

STEP 4: Complete and submit our online "Consumer Complaint" form and attach all the documents that you saved to your computer in STEP 3.  

*IMPORTANT: The Consumer Complaint system only allows you one opportunity to attach all the documents that pertain to your request for dispute resolution. It is important that you complete STEP 2 and STEP 3 before going to the online portal so you will be able to upload all your documents as part of your request for arbitration.  The Consumer Complaint system will transfer your documents to us in a secure, encrypted manner.  

If you were unable to attach all related documents, do NOT submit a new request.  You may contact us at [email protected] and we will provide an alternate method to obtain the documents.  Please make sure to reference your dispute number. 

ONLINE PORTAL:  sbs.naic.org/solar-web/pages/public/onlineComplaintForm/onlineComplaintForm.jsf?state=AZ


 

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.  

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-S: Informal Settlement Conference Scheduling Details

This form is completed and uploaded into the Surprise Out-of-Network Dispute Resolution System (SOONBDRS) by a health insurer to report the details as to the date, time and participation instructions for an informal settlement teleconference ("IST").

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.

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.

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.