Surprise Out-of-Network Bill Dispute Resolution FAQ
The following are answers to frequently asked questions concerning Arizona's surprise out-of-network billing dispute resolution process. Information on this page does not constitute a legal opinion.
- "ADOI" means "Arizona Department of Insurance."
- "Disclosure notice" means the notice that a healthcare provider gives to an enrollee/patient that discloses the identity of the provider, the estimated cost of the healthcare services and <INSERT MORE TEXT HERE>.
- "Emergency treatment" (defined in ARS § 20-2803(A))
- "IST" means "informal settlement teleconference." If a request for dispute resolution qualifies for the arbitration process, the enrollee or the enrollee's authorized representative must participate in a telephone call with the healthcare provider and insurance company to try to settle the surprise bill.
- "SOONBDR" means "Surprise out-of-network bill dispute resolution."
Q & A - For Enrollees/Members
STATEMENT: I believe the ADOI should change the SOONBDR laws.
RESPONSE: The ADOI administers laws created and amended through the legislative process.
The ADOI has no authority to create laws or to enforce laws that are not on the books. Ideas for improving SOONBDR laws should be directed to legislators for consideration. Information about the Arizona State Legislature is available from their website at https://www.azleg.gov.
QUESTION: Can the ADOI allow SOONBDR for a surprise bill for a healthcare service that was provided before January 1, 2019?
ANSWER: No. The SOONBDR laws only apply to healthcare services provided on or after January 1, 2019 (regardless of when you received bills for those services).
Consider calling 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.
If you believe that the insurance company violated Arizona law or did not pay the health care claim in accordance with your health insurance policy, our Consumer Protection Division may be able to help. Visit our COMPLAINT website at https://insurance.az.gov/complaint to determine whether to file a complaint with us.
QUESTION: What happens if I need emergency treatment and either I am incapacitated or I am told that an in-network provider is not available?
- In some cases, insurance policies cover out-of-network services for emergency care. Check your policy to learn if this is the case.
- You do not need to worry about the impact of signing documents in order to be eligible for the SOONBDR process when receiving emergency care (defined in ARS § 20-2803(A)) at an in-network facility, or when receiving in-patient healthcare services relating to the emergency care at an in-network facility. ARS § 20-3113(A). Covered services provided in an emergency are generally eligible for the SOONBDR process even when a dislcosure notice is signed.
QUESTION: What do I do if I arrive for (non-emergency) treatment, am told that an in-network provider is not available and that an out-of-network provider is available?
- Take steps to avoid getting a surprise bill. Check out the "How can I protect myself from surprise bills?" section of our Surprise Out-of-network Bill Dispute Resolution webpage for some ideas.
- Ask if your insurance company has preauthorized payment of the out-of-network provider for your healthcare service.
- Always review documents that a healthcare provider asks you to sign and consider amending or refusing to sign documents that would make you responsible for costs for which you do not agree you should be responsible.
- If a healthcare provider wants you to sign on a digital pad, you can refuse to sign digitally and ask the provider for a hardcopy to review and sign.
Q & A - For Insurers and Employers
QUESTION: Is an enrollee who is covered by a self-insured plan that is not preempted by the Employee Retirement Income Security Act (ERISA) able to request arbitration for a surprise bill?
ANSWER: Yes (because the plan is not preempted by ERISA).
When an employer provides health benefits coverage to its employees,
- the employer can choose to purchase health insurance, for which the insurer takes on the risks associated with collecting enough premiums to be able to pay claims; or,
- the employer can establish a self-insured plan, for which the employer (usually with an insurance company acting as a plan administrator) pays claims for health care services for the employees and dependents. In the ERISA, the federal government has legislated that most self-insured plans will not be subject to state insurance regulation. This federal "preemption," however, does not apply to some self-funded government and church employee health plans.
Arizona Revised Statutes ("ARS") § 20-3112 identifies circumstances when ARS Title 20, Chapter 20, Article 2 (Out-of-network Claim Dispute Resolution) does not apply. Paragraph 6 states Article 2 does not apply to "6. A self-funded or self-insured employee benefit plan if the regulation of that plan is preempted by the employee retirement income security act of 1974 (P.L. 93-406; 88 Stat. 829; 29 United States Code section 1144(b))." (Emphasis added)
The definition of "health plan" includes the phrase "and that is issued by a health insurer." Without ARS § 20-3112(6), members of all self-insured plans would have been ineligible for the SOONBDR process (because technically, insurers do not 'issue' health insurance for self-insured plans, but instead, 'administer' benefits for those plans). The original version of Article 2, enacted in Laws 2017, Ch. 190, excluded ARS § 20-3112(6). Without that paragraph and given the definition of "health plan," members of all self-insured plans would have been ineligible for the SOONBDR process. However, Laws 2018, Ch. 272 amended Article 2, adding ARS § 20-3112(6), restricting the inapplicability of Article 2 to self-insured plans only when the regulation of the plan is preempted by ERISA.
Q & A - For Healthcare Providers
QUESTION: Under ARS § 20-3113(A)(2), what is considered a "reasonable amount of time" prior to rendering health care services by which an out-of-network provider must give an enrollee the required notice?
ANSWER: Arizona law does not define "reasonable amount of time." An out-of-network provider should give the notice to the enrollee as much in advance as is practicable, thereby giving the enrollee an opportunity to read, fully understand, ask questions about, and decide whether to sign the notice. NOTE: A provider may not withhold service to an enrollee who elects to not sign the notice.
QUESTION: Under ARS § 20-3113(A)(2)(b), what amount must a healthcare provider include in the notice to the enrollee?
ANSWER: ARS § 20-3113(A)(2)(b) says the notice must include "[t]he estimated total cost to be billed by the health care provider or the provider's representative."
QUESTION: Who may participate on behalf of the provider in the informal settlement teleconference? Is an attorney required to be present?
ANSWER: The provider may authorize anyone to represent the provider throughout the dispute resolution process. When the ADOI receives a request for dispute resolution, the ADOI will ask the provider to complete a "Request for Information From a Healthcare Provider" form, which will, in part, ask the provider for specific information about anyone appointed to represent the provider during the dispute resolution process.