Fill - Free fillable INSTRUCTIONS ArizonaDepartmentofInsurance Before you submit a request for (Arizona) PDF form

ArizonaDepartmentofInsurance

SURPRISEOUT‐OF‐NETWORKBILLING

DISPUTERESOLUTION(SOONBDR)

INSTRUCTIONS

Before you submit a request for surprise billing dispute resolution…

Itisimportantthatyouknowthefollowing:

1. Onlysubmitarequestfordisputeresolutionifeligible.Yourhealthinsurercanhelpyoudetermineeligibilityandcanprovide

informationyouneedtocompletetherequestform.ArizonaRevisedStatutes(“ARS”)§§20‐3111through20‐3119define

whichhealthcarebillsareeligibleforthedisputeresolutionprocess.Bylaw,thedisputeresolutionprocessdoesnotapplyto:

 AhealthcareservicetheenrolleereceivedbeforeJanuary1,2019;

 Ahealthcareserviceprovidedmorethanayearbeforetheenrolleesubmitsarequestforarbitration(extendedbyany

timethebillwasthesubjectofahealthcareappeal);

 Abillthatis$999.99orlessafterdeductingtheenrollee'scopay,coinsurance,anddeductible;

 Limitedbenefitcoverage;

 Healthandaccidentcoverageforstateemployeesandtheirdependents;

 Self‐fundedorself‐insuredemployeebenefitplanspreemptedbytheEmployeeRetirementIncomeSecurityActof1974

(a.k.a.ERISA)‐yourinsurancecardmayshow"ASO"or"AdministrativeServicesOnly"ifyouarecoveredunderaself‐

fundedplan;

 Healthplansthatexcludeout‐of‐networkcoverageunlessotherwiserequiredbylaw;

 Healthcareservicesthatarenotcoveredbythehealthplan;

 Healthcareservicesnotprovidedfromahospital,outpatientsurgicalcenter,laboratory,diagnosticimagingcenteror

urgentcarecenterthathasacontractwiththehealthinsurer("networkfacility");

 Providerorhealthfacilitychargesthatanindividualagreedtodirectlypayratherthanusingthehealthplan;

 Providerorhealthfacilitychargesforwhichtheenrolleesignedadisclosurenoticeonwhichtheenrolleewasprovided

informationrequiredbyArizonalaw,therebyresultingintheenrolleewaivingrightstoarbitrationiftheamountofthe

provider'sbillwasnogreaterthantheestimatedtotalcostthattheproviderincludedonthedisclosurenotice;

 Ahealthcareservicethatisthesubjectofahealthcareappealthathasnotbeendecided;

 Ahealthcarebillorhealthcareservicethatisthesubjectofalegalactionthattheenrolleeinitiated;

 Abillthatwaspreviouslysettledordecidedthroughthedisputeresolution(arbitration)process.

2. Onlysubmitarequestfordisputeresolutiononpaperifyoucannotsubmityourrequestonline.Youcanaccessthesecure,

onlineSurpriseOut‐of‐networkBillingDisputeResolution(SOONBDR)systemfromhttps://insurance.az.gov/soonbdr.

3. Whileinformationyousubmitwillgenerallybetreatedasconfidential,theinformationmaybesharedwiththehealthcare

providerwhobilledyouandthehealthcareprovider’sauthorizedrepresentativeandbillingcompany,withyourinsurance

companyandwithanarbitratorselectedtomakedecisionsaboutyourrequest.Whensendingsensitiveinformationbymail,

youshouldconsiderusingamethodthatwilltrackthedelivery.

4. Youwillneedtosubmitclearphotocopiesofthefollowingdocumentslistedonthelastpageoftherequestform.

 ESSENTIAL:Acopyofthebill(s)andstatement(s)youreceivedfromyourproviderthatarepartofthesurprisebilling;

 ESSENTIAL:Acopyofbothsidesofyourhealthinsurancecard(showingthenameoftheinsurancecompany,yourmember

number,planIDnumber,andotherinformation)

 ESSENTIAL:Acopyofthe“ExplanationofBenefits”thatyoureceivedfromyourinsurancecompany(showingtheamount

thehealthcareproviderbilledandtheamountthehealthinsurancecompanyhaspaid)

 HELPFUL:Acopyofanypayment(s)youmadetoyourproviderforcopayments,coinsurance,deductiblesoranyotherpart

oftheprovider’sinvoice;

 HELPFUL:Acopyofeachnoticeordocumentyouorsomeoneonyourbehalfsenttoorreceivedfromtheprovideror

insurerthatpertainstothehealthcareservicesorsurprisebillyoureceived.

SOONBDRRequest(v.20190103)|

SURPRISEOUT‐OF‐NETWORKBILLINGDISPUTERESOLUTION(SOONBDR)FORM

HealthCareAppealsSection

ArizonaDepartmentofInsurance

100N.15

Ave.,Ste.102,Phoenix,AZ85007‐2624

https://insurance.az.gov/soonbdr|(602)364‐2399

Enrollee Information

Enterinformationaboutthepersonwhoreceivedtheinvoiceforthehealthcareservices(the“enrollee”)

FirstName: MiddleName: LastName: Suffix(Jr./Sr./II/III/etc.):

E‐mailAddress: AreaCodeandPhoneNumber:

MailingAddress: City: State: ZIPCode:

Insurance Coverage Information

Enterinformationasitappearsonthepatient’sinsurancecard.

NameofInsuranceCompany:

MemberID# Group#

Patient Information

Enterinformationaboutthepatientwhoreceivedthehealthcareservicesthatresultedinthesurprisebill.

FirstName: MiddleName: LastName: Suffix(Jr./Sr./II/III/etc.):

DateofBirth: RelationshiptoEnrollee:

Healthcare Provider Details

Enteralltheinformationyouknowaboutthehealthcareproviderthatprovidedthehealthcareservicesthatare

presentedonthesurprisebill.

NameofHealthcareProvider: BusinessName(ifpartoftheaddress):

BillingAddressonBill City State ZIPCode

E‐mailAddress AreaCodeandPhoneNumber:

YOU MUST BE 18 YEARS OR OLDER TO

COMPLETE THIS FORM.

Same as Enrollee? Yes No

Clear Form

SOONBDRRequest(v.20190103)|2

Bill Details

Line1:Datethehealthcareserviceswereprovided(mm/dd/yyyy).Mustbeonor

after01/01/2019toqualifyforthedisputeresolutionprocess..........................................

Line2:Totalamountthatthe

healthcareproviderbilledtheenrolleeforthe

healthcareservice............................................................................................................... $

Line3:Requiredcopayment(thefixed

amountyourhealthinsuranceplanrequires

youtopaywhenyoureceivethistypeofout‐of‐networkhealthcareservice)................. $

Line4:Requiredcoinsurance(yourportionoftheamountthatyourhealthinsurance

planhasdesignatedistheallowedamounttobepaidtothehealthcareproviderfor

thistypeofout‐of‐networkhealthcareservice–forexample,iftheallowedamount

were$10,000.00andyourhealthplanrequiresyoutopay20%oftheallowedamount,

youwouldenter$2,000.00)............................................................................................... $

Line5:Deductibleremainingbeforethisbillforhealthcareservices(theamountyou

mustpayforhealthcareservicesbeforeyourhealthinsuranceplanwillbegintopay

healthcareexpenses–theamountofdeductiblethatyouneedtopayshouldbe

reflectedontheExplanationofBenefits(“EOB”)thatyourhealthinsuranceplan

providedyouafteryourreceivedhealthcareservices....................................................... $

Surprisebillamount:Line2minusLine3minusLine4minusLine5.Thisisthe

amountthatyouareentitledtodispute.Thisamountmustbeatleast$1,000.00for

youtobeeligibleforthedisputeresolutionprocess......................................................... $

Additional Eligibility Questions

1. Priortoreceivingthehealthcareservices,didtheenrolleesignanoticedisclosingthenameofthehealthcare

provider,thefactthattheproviderwasnotacontractedprovider,andtheestimatedcosttobebilledbythe

providerortheprovider’srepresentative? Yes No.Includeacopyofthenoticewiththisrequest.

 Wastheamountactuallybilledbythehealthcareprovidermorethantheestimatedtotalcostprovidedon

thenotice(evenifonlybyapenny)? Yes No.

2. Didtheinsurancecompanydenyaclaimforthehealthcareservicesthatareonthesurprisebill(e.g.theinsurance

companysaysthehealthcareserviceisnotcoveredunderthehealthplan)? Yes No.

3. Didyouinstitutealawsuitorotherlegalproceedingagainsttheinsurancecompanyorhealthcareproviderbecause

ofthesurprisebillingorrelatingtothehealthcareservice? Yes No.

4. Didtheenrolleepaytheprovidertheamountthatthehealthplanrequiresanenrolleetopayforhealthcare

services,includingcopayment,coinsuranceanddeductible? Yes No.

 Doestheenrolleehaveawrittenagreementwiththeprovidertopaythecopayment,coinsuranceand

deductible? Yes No.Includeacopyofthatagreementwithyourrequest.

5. Werethehealthcareservicesprovidedatafacilitythatis“in‐network”(contractedwithyourhealthinsuranceplan)?

Yes No.

6. Weretheservices“emergencyservices”? Yes No.

7. Weretheservicesprovidedafterthepatientwasformallyadmittedtoanetworkfacilityforadditionalassessment

ortreatmentfollowinganemergencyvisit? Yes No.

Enrollee: | Provider:

0.00

SOONBDRRequest(v.20190103)|3

Authorized Representative Information

Forthepurposesofthesurpriseout‐of‐networkbillingdisputeresolutionrequest,an“authorizedrepresentative”isa

personappointedtoactonbehalfoftheenrollee.Boththeenrolleeandtheauthorizedrepresentativewillreceive

notificationsaboutthestatusoftherequest,andeithertheenrolleeortheauthorizedrepresentativemustfulfill

requirementsfortherequesttoremainvalid.Ifneithertheenrolleenortheauthorizedrepresentativetimelyfulfilla

requirement,therequestfordisputeresolutionmaybedeniedandtheenrollee’srighttodisputeresolutionmaybe

forfeited.

Whoiscompletingthisform? Enrollee AuthorizedRepresentative

ENROLLEE:Doyouwishtoappointanindividualtoserveasyourauthorizedrepresentativeconcerningyour

requestfordisputeresolution? Yes No

Auth. Rep. FirstName:

MiddleName: LastName: Suffix(Jr./Sr./II/III/etc.):

E‐mailAddress: AreaCodeandPhoneNumber:

MailingAddress: City: State: ZIPCode:

______________________________________________________________

Date

_____________________

Enrollee: | Provider:

BY MY SIGNATURE BELOW, I HEREBY CERTIFY THAT I UNDERSTAND THE FOLLOWING: By designating an

authorized representative, I acknowledge that I understand that the authorized representative and I will receive

notifications about the status of the dispute resolution request, and that either the authorized representative or I must

fulfill requirements for the request to remain valid. If neither the authorized representative nor I timely fulfill a requirement,

my request for dispute resolution may be denied and I may forfeit my right to dispute resolution.

Signature of Enrollee

SOONBDRRequest(v.20190103)|4

Dispute Resolution Request Checklist

Includewiththisformclearphotocopiesofthefollowingdocuments:

 ESSENTIAL:Acopyofthebill(s)/statement(s)youreceivedfromyourhealthcareproviderthatarepartofthe

surprisebilling.

 ESSENTIAL:Acopyofbothsidesofyourhealthinsurancecard(showingthenameoftheinsurancecompany,

yourmembernumber,planIDnumberandotherinformation).

 ESSENTIAL:Acopyofthe“ExplanationofBenefits”(or“EOB”)documentthatyoureceivedfromyour

insurancecompany,whichshowstheamountthehealthcareproviderbilledandtheamountthehealth

insurancecompanyhaspaid.

 HELPFUL:Acopyofanypayment(s)youmadetothehealthcareproviderforcopayments,coinsurance,

deductiblesoranyotherpartoftheprovider’sinvoice.

 HELPFUL:Acopyofeachnotice,e‐mail,letterorotherdocumentyouorsomeoneonyourbehalfsenttoor

receivedfromthehealthcareproviderorhealthinsurerthatpertainstothehealthcareservicesorsurprisebill

youreceived.

 ESSENTIALIFYOUARETHEAUTHORIZEDREPRESENTATIVE:Ifyoucompletedthisformonbehalfofthe

enrollee,youmustincludeevidencethatyouhavethelegalauthoritytoactontheenrollee’sbehalf,suchasa

copyofacourtappointmentorcontractwiththeenrollee.

ATTESTATION

Bysigningbelow,youcertifyandattestthatallinformationprovidedinandaspartofthisrequestfordispute

resolutionistrueandcorrecttothebestofyourknowledgeandbelief.

PersonCompletingthisForm/Attestation: Enrollee

AuthorizedRepresentative

______________________________________________________________

Signature

_____________________

Date

Enrollee: | Provider:

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INSTRUCTIONS ArizonaDepartmentofInsurance Before you submit a request for (Arizona)

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Fill Online, Printable, Fillable, Blank INSTRUCTIONS ArizonaDepartmentofInsurance Before you submit a request for (Arizona) Form

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