Fillable ArizonaDepartmentofInsurance SURPRISEOUTOFNETWORKBILLINGDISPUTERESOLUTIONREQUEST INFORMALSETTLEMENTTELECONFERENCESCHEDULINGDETAILS Within21calendardaysafterreceivinginstructionsfromtheDepartmentto sch

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ArizonaDepartmentofInsurance SURPRISEOUTOFNETWORKBILLINGDISPUTERESOLUTIONREQUEST INFORMALSETTLEMENTTELECONFERENCESCHEDULINGDETAILS Within21calendardaysafterreceivinginstructionsfromtheDepartmentto scheduleaninformalsettlementteleconference(IST),theinsurerneedsto contacttheenrolleeandprovidertoschedulethedateand(Arizona)timefor theIST,andneedstouploadacompletedversionofthisformtoreportthe schedulingdetailstotheDepartment. (Arizona)

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SOONBDRIST‐S(v.20190502)|Page1of1
ArizonaDepartmentofInsurance
SURPRISEOUT‐OF‐NETWORKBILLINGDISPUTERESOLUTIONREQUEST
INFORMALSETTLEMENTTELECONFERENCESCHEDULINGDETAILS
Within21calendardaysafterreceivinginstructionsfromtheDepartmentto
scheduleaninformalsettlementteleconference(“IST”),theinsurerneedsto
contacttheenrolleeandprovidertoschedulethedateand(Arizona)timefor
theIST,andneedstouploadacompletedversionofthisformtoreportthe
schedulingdetailstotheDepartment.
ADOICase#:
InsurerNAIC#:
InsurerName:
InsurerContactPersonName:
Phone: Email:
WhowillparticipateforEnrollee(Name)?
Phone: Email:
WhowillparticipateforProvider(Name)?
Phone: Email:
ISTDate: ISTTime:
AMPMArizonaTime
Howwilltheinsurerconducttheinformalsettlementteleconference(“IST”)?
Bycreatingateleconferencecallbycallingouttoeachoftheparties
Byhavingthepartiescallintotheteleconferenceusingthefollowinginformation:
PhoneNumber:
Conference#: AudioPIN:
Other(describebelow):
UPLOADTHECOMPLETEDANDSAVEDVERSIONOFTHISDOCUMENTINTOTHESURPRISEOUT‐OF‐
NETWORKBILLINGDISPUTERESOLUTIONSYSTEMathttps://azinsurance.online/soonbdrs
QUESTIONS?Seeiftheanswerisonourwebsiteathttps://insurance.az.gov/soonbdr,andifnot,send
e‐mailtosoonbdr@azinsurance.gov,orcallourSurpriseOut‐of‐NetworkBillingDisputeResolution
Analystat(602)364‐2399.
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ArizonaDepartmentofInsurance SURPRISEOUTOFNETWORKBILLINGDISPUTERESOLUTIONREQUEST INFORMALSETTLEMENTTELECONFERENCESCHEDULINGDETAILS Within21calendardaysafterreceivinginstructionsfromtheDepartmentto scheduleaninformalsettlementteleconference(IST),theinsurer

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Completed 20 July 2020

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