Balance billing – or a surprise medical bill – happens when you get a bill from a doctor, laboratory, durable medical equipment provider, or other health care provider who isn’t part of your health plan’s network. Often, consumers didn’t know they were getting care from out-of-network providers. For example, a patient goes to an in-network hospital for emergency care and is treated by an out-of-network doctor. The doctor and the hospital each bill $1,000 for their services, and the health plan pays them each $400. The in-network hospital can only bill the patient for copays, deductibles, and coinsurance amounts. The out of network doctor, however, may bill for copays, deductibles, and coinsurance as well as any other amounts that the health plan did not pay.
The SOONBDR program is deﬁned in Arizona Revised Statutes 20-3111 through 20-3119, and Arizona Administrative Code R20-6-2401through R20-6-2406
Arizona’s SOONBDR program has some eligibility requirements. Since the program began in 2019, more than half of the surprise billing complaints received by the AZ DIFI have been found not to be eligible for the SOONBDR program. The most common reasons that surprise bills are not eligible:
- The policy is not under our jurisdiction (e.g., self-insured by employer, state or federal government employee plan, policy issued in another state)
- The date of the health care service was more than 1 year ago (although it can be extended by the time a health care appeal was in progress)
- The amount of the bill is less than $1,000
- It is an HMO plan (these plans have other balance billing protections)
We have a form you can ﬁll out (below) that will give us the information needed to evaluate whether your surprise bill qualiﬁes for the Arizona SOONBDR, health care appeals or complaint process. If your surprise bill qualiﬁes for the Arizona SOONBDR program, we’ll let you know the next steps. Generally, an informal settlement conference will be set up, which requires the participation of the enrollee. The vast majority of complaints that qualify for the SOONBDR program are resolved informally; however, if no resolution is reached, the dispute can proceed to arbitration. There is no cost to an enrollee to participate in Arizona’s SOONBDR program.
If your surprise bill is not under our jurisdiction, we will provide you with information on how to contact the agency or entity that may be able to provide you with assistance.
STEP 1: Complete Form SOONBDR (Surprise Out-of-Network Billing Dispute Resolution Request), and print and sign the form.
STEP 2: Scan and save to your computer:
- The Form SOONBDR that you completed and signed in STEP 1
- A picture of your insurance card, front and back
- Correspondence (letters, memos, bills, etc.) between you, the provider, and the insurer relating to this bill
- Any other information you have that will help explain this matter
STEP 3: Complete and submit via our online "Consumer Complaint" system and attach all the documents that you saved to your computer in STEP 2.
*IMPORTANT: The Consumer Complaint system only allows you one opportunity to attach all the documents that pertain to your request for dispute resolution. It is important that you complete STEPS 1 and 2 before going to the online portal.
If you were unable to attach all related documents, do NOT submit a new request. Contact us at [email protected]ﬁ.az.gov and we will provide an alternate method for you to submit the documents. Please make sure to reference your Consumer Complaint number.
|Arizona's Surprise Bill Resolution Report for 2020||As shown in the attached report prepared pursuant to A.R.S. § 20-3118(A), the Department of Insurance and Financial Institutions received 214 requests for dispute resolution in Calendar Year 2020. 245 (includes 20 that carried over from 2019) have been resolved or closed, and health plan enrollees saved $349,153.87 by submitting their surprise bills for resolution.|
|Arizona's Surprise Bill Resolution Report for 2021||As shown in the attached report prepared pursuant to A.R.S. § 20-3118(A), the Department of Insurance and Financial Institutions received 342 requests for dispute resolution in Calendar Year 2021. 341 (includes 37 that carried over from 2020) have been resolved or closed, and health plan enrollees saved $487,483.62 by submitting their surprise bills for resolution.|
|Arizona's Surprise Bill Resolution Report for 2022||As shown in the attached report prepared pursuant to A.R.S. § 20-3118(A), the Department of Insurance and Financial Institutions received 427 requests for dispute resolution in Calendar Year 2022. 437 (includes 37 that carried over from 2021, and 27 that remained open as of 12/31/22) have been resolved or closed, and health plan enrollees saved $860,241.72 by submitting their surprise bills for resolution.|