Fillable INSTRUCTIONS ArizonaDepartmentofInsurance and Financial Institutions Before you submit (Arizona)

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INSTRUCTIONS ArizonaDepartmentofInsurance and Financial Institutions Before you submit (Arizona)

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ArizonaDepartmentofInsurance and Financial Institutions
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applyto:
• Balance billings on health policies issued or renewed on or after January 1, 2022 (see Federal No Surprises Act) https://
www.cms.gov/nosurprises;
• 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://difi.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.202201)|
1
SURPRISEOUT‐OF‐NETWORKBILLINGDISPUTERESOLUTION(SOONBDR)FORM
Consumer Services / HealthCareAppealsSection
ArizonaDepartmentofInsuranceand Financial Institutions
100N.15
th
Ave.,Ste.261,Phoenix,AZ85007‐2630
https://difi.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.202201|2
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 on a policy issued or renewed prior to 1/1/2022.
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.
0.00
Enrollee:
Bill Details:
SOONBDRRequest(v.202201)|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.
click to sign
signature
click to edit
SOONBDRRequest(v.202201)|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
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INSTRUCTIONS ArizonaDepartmentofInsurance and Financial Institutions Before you submit (Arizona)

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Completed 1 July 2022

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