Surprise Out-of-network Bill Dispute Resolution


Other Questions?

For questions about surprise billing that were not answered by this webpage, please send e-mail to [email protected], or call (602) 364-2399.

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.

Surprise Out-of-network Bill Dispute Resolution Notice to Enrollees for EOBs and Providers

Health care insurers and health care providers must give this notice to enrollees pursuant to ARS § 20-3117.

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.