Fillable ArizonaDepartmentofInsurance SURPRISEOUTOFNETWORKBILLINGDISPUTERESOLUTIONREQUEST REQUESTFORINFORMATIONFROMTHEHEALTHCAREPROVIDER TheArizonaDepartmentofInsurancereceivedarequestfor arbitrationforasurpri

Fill Online, Printable, Fillable, Blank ArizonaDepartmentofInsurance SURPRISEOUTOFNETWORKBILLINGDISPUTERESOLUTIONREQUEST REQUESTFORINFORMATIONFROMTHEHEALTHCAREPROVIDER TheArizonaDepartmentofInsurancereceivedarequestfor arbitrationforasurpri Form

Use Fill to complete blank online ARIZONA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

ArizonaDepartmentofInsurance SURPRISEOUTOFNETWORKBILLINGDISPUTERESOLUTIONREQUEST REQUESTFORINFORMATIONFROMTHEHEALTHCAREPROVIDER TheArizonaDepartmentofInsurancereceivedarequestfor arbitrationforasurpriseoutofnetworkbill.Failureto respondtothisrequestwithin15calendardayswillcause therequesttobedeemedeligibleforarbitration. (Arizona)

On average this form takes 22 minutes to complete

The ArizonaDepartmentofInsurance SURPRISEOUTOFNETWORKBILLINGDISPUTERESOLUTIONREQUEST REQUESTFORINFORMATIONFROMTHEHEALTHCAREPROVIDER TheArizonaDepartmentofInsurancereceivedarequestfor arbitrationforasurpri form is 3 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 86 other fields

Country of origin: US
File type: PDF

BROWSE ARIZONA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
SOONBDRFI‐P(v.20181227)|Page1of3
ArizonaDepartmentofInsurance
SURPRISEOUT‐OF‐NETWORKBILLINGDISPUTERESOLUTIONREQUEST
REQUESTFORINFORMATIONFROMTHEHEALTHCAREPROVIDER
TheArizonaDepartmentofInsurancereceivedarequestfor
arbitrationforasurpriseout‐of‐networkbill.Failureto
respondtothisrequestwithin15calendardayswillcause
therequesttobedeemedeligibleforarbitration.
ADOICase#: NoticeDate:
InsurerNAIC#: InsurerName:
Insured’sName: MemberIDNumber: GroupNumber:
Patient’sName: DateofBirth: RelationshiptoInsured:
Whoisrepresentingtheproviderinthisdisputecase?Theselectedrepresentative[A]willreceive
notificationsaboutthestatusofthebillingdispute;[B]musttimelyfulfillstepssetforthinArizonalaw
topreventarequestfrombeingdeemedeligibleforarbitrationandtopreventtheproviderfrom
havingtopaytheentirecostsofarbitration,and[C]hasthefullauthoritytoactonbehalfofthe
providerinthismatterandtobindtheproviderlegallyandfinanciallyconcerningthismatter.
HealthcareProvider/SelfBillingCompany AuthorizedRepresentative
ProviderName: Phone: E
mail:
NameofProviderGroup(ifpartoftheaddress):
MailingAddressforProvider: City: State: ZIPCode:
NameofProvider’sBillingCompany: BillingCompanyContactPerson’sName:
Phone: Email:
MailingAddressforBillingCompany: City: State: ZIPCode:
NameofProvider’sAuthorizedRepresentative: BusinessName(ifpartofmailingaddress):
Phone: Email:
MailingAddressforAuthorizedRepresentative: City: State: ZIPCode:
Clear Form
As part of the response to this Request for Information, you must upload a document signed by the provider
giving the representative authority to legally and financially bind the provider in this matter.
SOONBDRFI‐P(v.20181227)|Page2of3
HealthcareServiceDate: $BilledbyPro
vider: $PaidbyInsurer:
EnrolleeCopayment$: Coinsurance$: Deductible$: $PaidbyEnrollee:
UnpaidCost‐sharing: Hastheenrolleearrangedinwritingtopaytheunpaidcost‐sharingamount?
WhichStateofArizonaagency,boardorcommissionissuedyou
thelicensetoprovidethetypeofhealthcareserviceyou
providedrelatingthisbillingdisputecase?
License#: Type/ClassofLicense: Dateissued: Expirationdate:
InwhatArizonacountywerehealthcareservicesprovided?
Weretheservicesprovidedinacontractednetworkfacility?
Yes No
Inwhattypeoffacilitywasthehealthcareserviceprovided:
HospitalOutpatientsurgicalcenterLaboratoryDiagnosticimagingcenter
UrgentcareOther:____________________________________________________
Wastheprovidercontractedwiththehealthinsureronthedatethe
healthcareservicewasprovided?
Yes No
Weretheserviceseither“emergencyservices”orhealthcareservices
directlyrelatedtoanemergencyprovidedduringaninpatient
admission?
PerArizonaRevisedStatute§20‐2801(3):“"Emergencyservices"means
healthcareservicesthatareprovidedtoanenrolleeinalicensedhospitalemergency
facilitybyaprovideraftertherecentonsetofamedicalconditionthatmanifestsitself
bysymptomsofsufficientseveritythattheabsenceofimmediatemedicalattention
couldreasonablybeexpectedtoresultinanyofthefollowing:(a)Seriousjeopardyto
thepatient'shealth,(b)Seriousimpairmenttobodilyfunctions,(c)Seriousdysfunction
ofanybodilyorganorpart.”
Yes No
DidyouprovideanoticetotheenrolleeinaccordancewithA.R.S.§20‐
3113(A)(2)thatprovidedallthefollowinginformation?
Thenameofthehealthcareproviderandnoticethatthe
providerisnotacontractedprovider,
Theestimatedcostthattheproviderwouldbillforthe
healthcareservice,
Noticethattheenrolleeisnotrequiredtosignthenoticeto
receivethehealthcareservice,and
Noticethatbysigningthenotice,enrolleewaivestherightto
arbitrationforthebill.
Yes No
Case # | Provider:
Provider bill less insurer payment less cost-sharing IS LESS THAN $1,000:
$ 0.00
$ 0.00
Maricopa
SOONBDRFI‐I(v.20181227)|Page3of3
Isahealthcareappealcurrentlypendingonthehealthcareservices
thatarethesubjectofthesurprisebill?
Yes
No/Unknown
Wasahealthcareappealpreviouslydecidedforthehealthcare
servicesthatarethesubjectofthesurprisebill?
Yes No/Unknown
Iftheresponsetothepreviousquestionwas“Yes,”onwhat
datesweretheappealsubmittedanddecidedbytheinsurer?
Submitted
(mm/dd/yyyy)
Decided
(mm/dd/yyyy)
IfthehealthcareappealwassubmittedtotheDepartmentof
Insurance,whenwastheappealsubmittedanddecided?
Submitted
(mm/dd/yyyy)
Decided
(mm/dd/yyyy)
Didtheenrolleeinstituteacivillawsuitorotherlegalactionagainstthe
insurerorhealthcareproviderrelatedtothesurpriseout‐of‐network
billorthehealthcareservicesprovided?
Yes
No/Unknown
UPLOADALLTHEFOLLOWINGDOCUMENTSINTOTHESURPRISEOUT‐OF‐NETWORKBILLING
DISPUTERESOLUTIONSYSTEMathttps://azinsurance.online/soonbdrs
AfullycompletedandsavedversionofthisRequestForInformationform.
Acopyofthebill(s),statement(s)andcorrespondenceissuedtotheenrolleeasitrelatesto
theamountsowed.
Ifthehealthcareservicewasnotprovidedfor,ordirectlyrelatedto,emergencyservices,you
mustprovideacopyofthewritten,dateddisclosurethatyouprovidedtotheenrolleethat:
o statesthenameofthehealthcareproviderandthattheproviderisnotacontracted
provider,
o providestheestimatedcostthattheproviderwouldbillforthehealthcareservice,
o providesnoticethattheenrolleeisnotrequiredtosignthenoticetoreceivethe
healthcareservice,andthatbysigningthenotice,enrolleewaivestherightto
arbitrationforthebill.
Iftheenrolleesignedthedisclosurenotice,youmustprovideacopyofthesignednotice.
Acopyofeachexplanationofpayments(EOP)youreceivedfromtheenrollee’shealth
insurerthatpertainstothisbillingdisputecase.
Ifthehealthcareproviderisbeingrepresentedbytheprovider’sbillingcompanyorbyan
authorizedrepresentative,adocumentsignedbytheprovidergivingtherepresentativethe
authoritytol
egallyandfinanciallybindtheproviderinthismatter.
QUESTIONS?Seeifthea
nswer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
Teamat(602)364‐2399.
Case # | Provider:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

ArizonaDepartmentofInsurance SURPRISEOUTOFNETWORKBILLINGDISPUTERESOLUTIONREQUEST REQUESTFORINFORMATIONFROMTHEHEALTHCAREPROVIDER TheArizonaDepartmentofInsurancereceivedarequestfor arbitrationforasurpriseoutofnetworkbill.Failureto respondtothisrequestwithin

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document