Form SOONBDRIST-S: Informal Settlement Conference Scheduling Details

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).

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").

PDF icon Form SOONBDRIST-S
Priority: 
01100
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: 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.