What are the steps involved in the dispute resolution (arbitration) process?

The following is an overview of the dispute resolution process:

  • The enrollee submits a request for dispute resolution to the Arizona Department of Insurance ("Department").
  • The Department evaluates the request to determine whether it may qualify for arbitration, and if it doesn't, the Department notifies the enrollee of the reason the request did not qualify for arbitration (and the process ends).
  • OTHERWISE, the Department sends the enrollee's request for dispute resolution to the insurer and the health care provider and may ask for additional information from the enrollee, the insurer and the provider to help the Department make a final decision as to whether the surprise bill is eligible for the arbitration process,
    • If the enrollee does not respond to a Department request for additional information, the enrollee's request for dispute resolution is deemed to have been withdrawn, and the Department will notify the enrollee of this fact (and the process ends).
    • If the healthcare provider or health insurer does not timely respond to a Department request for additional information, the dispute resolution case will automatically be determined eligible for the dispute resolution process.
    • If the Department determines from information provided that the surprise bill does not qualify for the dispute resolution process, the Department will notify the enrollee of the reason (and the process ends). 
  • OTHERWISE, the Department arranges an informal settlement teleconference (IST) in which the enrollee (or authorized representative), insurer and provider (or authorized representative) must all participate.
    • If the enrollee participates in the IST, the insurer will notify the Department of the outcome and the enrollee can only be held responsible for paying the amount of the enrollee's cost-sharing requirements (copay, coinsurance, and deductible) plus any amount the health insurer paid the enrollee for the services provided by the out-of-network health care provider.
    • If the enrollee does not participate, within 14 days of missing the IST, an enrollee is allowed one opportunity to request that another IST become scheduled. 
    • If the enrollee does not request the rescheduling of the IST within 14 days or does not participate in a rescheduled IST, the enrollee forfeits the right to have the surprise bill arbitrated, and the Department will notify the enrollee of this fact (and the process ends).
    • If either the provider or insurer fails to participate in the IST, the enrollee's request will be referred for arbitration.
  • If the IST did not resolve the dispute between the insurer and provider, the Department will work with the insurer and provider to determine the arbitrator that will decide the dispute.  The enrollee may decide whether to participate or not participate in the arbitration proceeding.  Regardless of whether the enrollee participates in the arbitration proceeding, by virtue of having participated in the IST, the enrollee can only be held responsible for paying the amount of the enrollee's cost-sharing requirements (copay, coinsurance and deductible) plus any amount the health insurer paid the enrollee for the services provided by the out-of-network health care provider. 
  • The arbitrator will conduct the arbitration (with or without the enrollee), the arbitrator will determine the amount that the provider is entitled to be paid for the health care services the enrollee was provided, and the arbitrator will provide a final written decision to the enrollee, to the insurer and to the health care provider or authorized representative (and the process ends).