SOONBDR News

1/17/2019:  We are working with a vendor to create an easy-to-use system for submitting requests for surprise bill dispute resolution requests, and we estimate that system will be available starting February 17, 2019.  We will also publish a form that a person can complete and submit through the mail with required attachments; however, submitting information using the online system will likely be easier and less expensive. 

IMPORTANT!  Requests can only be submitted for health care services a person received on or after January 1, 2019.  A person should first work with the health insurer to determine the amount the portion of the bill that the insurer will pay and whether the bill qualifies for the dispute resolution process under Arizona law.  For additional information, view the section of this webpage entitled, "I got a surprise bill. What can I do about it?"

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: 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.