What is a "surprise bill"?

Balance billing – or a surprise medical bill – happens when you get a bill from a doctor, laboratory, durable medical equipment provider, or other health care provider who isn’t part of your health plan’s network. Often, consumers didn’t know they were getting care from out-of-network providers.  For example, a patient goes to an in-network hospital for emergency care and is treated by an out-of-network doctor. The doctor and the hospital each bill $1,000 for their services, and the health plan pays them each $400. The in-network hospital can only bill the patient for copays, deductibles, and coinsurance amounts. The doctor, however, may bill for the copays, deductibles, and coinsurance as well as any other amounts that the health plan did not pay. 

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.