Fillable ArizonaDepartmentofInsurance SURPRISEOUTOFNETWORKBILLINGDISPUTERESOLUTIONREQUEST REQUESTFORINFORMATIONHEALTHINSURER TheArizonaDepartmentofInsurancereceivedarequestfor arbitrationforasurpriseoutofnetwo

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ArizonaDepartmentofInsurance SURPRISEOUTOFNETWORKBILLINGDISPUTERESOLUTIONREQUEST REQUESTFORINFORMATIONHEALTHINSURER TheArizonaDepartmentofInsurancereceivedarequestfor arbitrationforasurpriseoutofnetworkbill.Failureto respondtothisrequestwithin15calendardayswillcause theenrolleesrequesttobedeemedeligibleforarbitration. (Arizona)

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SOONBDRFI‐I(v.20190207)|Page1of2
ArizonaDepartmentofInsurance
SURPRISEOUT‐OF‐NETWORKBILLINGDISPUTERESOLUTIONREQUEST
REQUESTFORINFORMATION‐HEALTHINSURER
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enrollee’srequesttobedeemedeligibleforarbitration.
ADOICase#: NoticeDate:
InsurerNAIC#:
InsurerName:
InsurerContactPersonName:
Phone: Email:
MailingAddress: City: State: ZIPCode:
Insured’sName: MemberIDNumber: GroupNumber:
Patient’sName: DateofBirth:
RelationshiptoInsured:
ProviderName:
Phone: Email:
ProviderGroupName:
DateofService:
$BilledbyProvider*: $PaidbyInsurer*:
Copayment$*:
Coinsurance$*: Deductible$*: Enrollee’sBalance*:
*EncloseassociatedEOBsandEOPs
Whatisthehealthcareprovider’sspecialtyareaasitrelatestothesurprisebilling?
AnesthesiologyAudiologyCardiologyDermatology
EmergencyPhysicianEndocrinologyEquipment(DurableMedical)
GastroenterologyHematologyImmunologyOtolaryngologyPainManagement
NeurologyObstetrics/GynecologyOptometry/OphthalmologyOralSurgery
OrthopedicsPathologyPharmacyPhysicalRehabilitation
Plastic/ReconstructiveSurgeryPodiatryPsychiatry/Psychology/BehaviorPulmonology
RadiologyUrologyOther:_____________________________________________________
Whattypeofhealthcareservicewasprovided?
AnesthesiologyDrug/AlcoholTreatmentEmergencyEquipment(DME)
Laboratory/PathologyOrthopedicPhysical/OccupationalRehabilitationDrugs/Medicine
RadiologySurgeryOther:_____________________________________________________
Inwhattypeoffacilitywasthehealthcareserviceprovided?
HospitalOutpatientSurgicalCenterHealthCareLaboratoryDiagnosticImagingCenter
UrgentCareCenterOther:_______________________________________________________
InwhatArizonacountywerehealthcareservicesprovided?
Weretheservicesprovidedinacontractednetworkfacility?
Yes No
$ 0.00
Maricopa
SOONBDRFI‐I(v.20190207)|Page2of2
Wastheprovidercontractedonthedateofservice?
Yes No
Weretheserviceseither“emergencyservices”orservicesdirectly
relatedtoanemergencyprovidedduringaninpatientadmission?
Yes No
Wasthecoverageissuedtoaninsured/policyholderlocatedinArizona?
Yes No
DoestheenrolleeresideinArizona?
Yes No
Whichofthefollowingdescribesthehealthinsurancecoverage:

Thecoverageisfullyinsured

Thecoverageisaself‐insuredplanthatwasNOTpreemptedbyERISA
Thecoverageisaself‐insuredplanthatwaspreemptedbyERISA
Thecoverageisaself‐insuredplancoveringArizonastategovernmentemployees
Typeofpolicy(forPOS,use
HMOorPPOasapplicable)
HMO/HCSO/EPO PPO LimitedBenefit
Other:_________________________________________________
Wastheservicecovered(notdenied)undertheenrollee’shealthplan?
Yes No
Isahealthcareappealcurrentlypendingonthehealthcareservices
thatarethesubjectofthesurprisebill?
Yes No
Wasahealthcareappealpreviouslydecidedforthehealthcare
servicesthatarethesubjectofthesurprisebill?
Yes No
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or
unknown
Ifthebillingdisputeresolutionrequestisdeterminedtobeeligibleforarbitration,indicatehowthe
insurerwill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ALLTHEFOLLOWINGDOCUMENTSINTOTHESURPRISEOUT‐OF‐NETWORKBILLING
DISPUTERESOLUTIONSYSTEMathttps://azinsurance.online/soonbdrs
Thecompletedandsavedversionofthisdocument
Acopyofeachexplanationofbenefits(EOB)senttotheenrolleepertainingtothiscase
Acopyofeachexplanationofpayments(EOP)senttotheproviderpertainingtothiscase
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.
Case # | :
✔
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ArizonaDepartmentofInsurance SURPRISEOUTOFNETWORKBILLINGDISPUTERESOLUTIONREQUEST REQUESTFORINFORMATIONHEALTHINSURER TheArizonaDepartmentofInsurancereceivedarequestfor arbitrationforasurpriseoutofnetworkbill.Failureto respondtothisrequestwithin15calendarda

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Completed 20 July 2020

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