Page 1, between lines 1 and 2, insert:
"Section 1. Section 20-2540, Arizona Revised Statutes,
is amended to read:
START_STATUTE20-2540. Health
care appeals fund
A. The
health care appeals fund is established consisting of monies collected pursuant
to subsection B of this section. The fund is a special state fund pursuant to
section 35‑142, subsection A, paragraph 8. Monies in the fund do not
revert to the state general fund. The department shall administer the fund.
Monies in the fund are continuously appropriated and are exempt from the provisions
of section 35‑190 relating to lapsing of appropriations.
B. The
director shall charge an appealing member's health care insurer for all amounts
owed to the independent review organization, pursuant to subsection C of this
section, to decide the member's appeal. The director may assess each health
care insurer for administrative costs for implementing and maintaining the
external independent review process as prescribed in this section and section
20‑2538. The director shall deposit all collected monies in the fund.
C. The
director shall use monies in the fund to:
1. Compensate
procured independent review organizations for performing independent medical
reviews on a per case rate unless the director determines that another method
is necessary to carry out the purposes of this article.
2. Perform
the responsibilities relating to the procurement of independent review
organizations and to implement and maintain the external independent review
process.
3. Perform
the administrative function of the out‑of‑network claim dispute
resolution process prescribed in chapter 20, article 2 of this title.
D. An
independent review organization shall submit to the director for approval a
detailed invoice consistent with the method of payment prescribed in subsection
C of this section. END_STATUTE
Sec. 2. Heading change
The article
heading of title 20, chapter 20, article 2, Arizona Revised Statutes, is
changed from "out‑of‑network claim dispute
resolution" to "out‑of‑network
surprise bills and balance bills dispute resolution"."
Renumber to
conform
Page 1,
between lines 10 and 11, insert:
"3. "Balance bill" means the difference between
the health care provider's billed charge and the health care services organization's
allowed amount for a covered health care service under an enrollee's health
care plan as defined in section 20‑1051."
Renumber to
conform
Line 17,
after "insurer" insert "or health care services
organization"
Page 2,
between lines 12 and 13, insert:
"12. "Health care services organization" has the
same meaning prescribed in section 20‑1051."
Renumber to
conform
Line 14,
strike "health care services organization,"
Lines 19 and
21, after "insurer" insert "or health care
services organization"
Page 3,
between lines 19 and 20, insert:
"C. This section does not negate or limit a health care
services organization's obligation to its members to ensure that covered health
care services are delivered in accordance with each member's health care plan
as defined in section 20‑1051.
D. A
health care services organization enrollee is not a party to any payment
dispute between the health care services organization and a health care
provider. Both the health care services organization and health care provider
shall hold the enrollee harmless for disputed amounts that exceed the
enrollee's in‑network cost sharing amount.
Sec. 5. Section
20-3114, Arizona Revised Statutes, is amended to read:
START_STATUTE20-3114. Health
care insurers; dispute resolution; settlement teleconference; arbitration;
surprise out‑of‑network bills
A. An
enrollee who has received a surprise out‑of‑network bill and who
disputes the amount of the bill may seek dispute resolution of the bill by filing
a request for arbitration with the department not later than one year after the
date of service noted in the surprise out‑of‑network bill, except
as otherwise provided in this section, if all of the following apply:
1. The
enrollee has resolved any health care appeal pursuant to chapter 15, article 2
of this title that the enrollee may have had against the health insurer
following the health insurer's initial adjudication of the claim. The one‑year
time period for requesting arbitration is tolled from the date that the
enrollee files a health care appeal until the date of final resolution of the
appeal.
2. The
enrollee has not instituted a civil lawsuit or other legal action against the health insurer or health care provider related to the same
surprise out‑of‑network bill or the health care services provided.
3. The
amount of the surprise out‑of‑network bill for which the enrollee
is responsible for all related health care services provided by the health care
provider whether contained in one or multiple bills, after deduction of the
enrollee's cost sharing requirements and the health insurer's
allowable reimbursement, is at least one thousand dollars $1,000.
B. If
an enrollee requests dispute resolution of a surprise out‑of‑network
bill, the enrollee or the enrollee's authorized representative shall
participate in an informal settlement teleconference and may participate in the
arbitration of the bill. If the enrollee or enrollee's authorized
representative fails to attend the informal settlement teleconference, the conference teleconference shall be
terminated and the enrollee, within fourteen days after the first scheduled
informal settlement teleconference, may request that the department reschedule
the informal settlement teleconference. If the enrollee does not
request that the department reschedule the informal settlement teleconference,
the enrollee forfeits the right to arbitrate the surprise out‑of‑network
bill. The health care provider or the health care provider's
representative and the health insurer shall participate in the informal
settlement teleconference and the arbitration.
C. An
enrollee may not seek dispute resolution of a bill if the enrollee or the
enrollee's authorized representative signed the disclosure prescribed in
section 20‑3113, subsection A, paragraph 2 and the amount actually billed
to the enrollee is less than or equal to the estimated total cost provided in
the disclosure. END_STATUTE
Sec. 6. Title
20, chapter 20, article 2, Arizona Revised Statutes, is amended by adding
section 20-3114.01, to read:
START_STATUTE20-3114.01 Health
care services organizations; dispute resolution; settlement teleconference;
arbitration; balance bills
A. A
health care services organization that receives or a health care provider that
seeks to collect a disputed balance bill may seek dispute resolution of the
balance bill by filing a request for arbitration with the department not later
than one year after the date of service noted in the claim to which the balance
bill applies, Except as otherwise provided in this section, if all of the
following apply:
1.
The enrollee for the claim at issue has resolved any health care appeal
pursuant to chapter 15, article 2 of this title that the enrollee may have had
against the health care services organization following the health care
services organization's initial adjudication of the claim. The one-year time
period for requesting arbitration is tolled from the date that the enrollee
files a health care appeal until the date of final resolution of the appeal.
2.
The enrollee has not instituted a civil lawsuit or other legal action against
the health care services organization or health care provider related to the
same claim or the health care services provided.
3.
The amount of the balance bill for which the health care services organization
is responsible is at least $1,000.
B.
If a health care services organization requests dispute resolution of a balance
bill, the health care provider or the health care provider's authorized
representative shall participate in an informal settlement teleconference with
an authorized health care services organization representative. If the health
care provider or the health care provider's representative fails to attend the
informal settlement teleconference, the teleconference shall be terminated and
the health care services organization, within fourteen days after the scheduled
informal settlement teleconference, may request that the department set the
case for arbitration.
END_STATUTE
Sec. 7. Section
20-3115, Arizona Revised Statutes, is amended to read:
START_STATUTE20-3115. Conduct
of arbitration proceedings
A. The
department shall develop a simple, fair, efficient and cost‑effective
arbitration procedure for surprise out‑of‑network bill and balance bill disputes and specify time frames, standards
and other details of the arbitration proceeding, including procedures for
scheduling and notifying the parties of the settlement teleconference required
by subsection E of this section. The department shall contract with
one or more entities to provide arbitrators who are qualified under section 20‑3116
for this process. Department staff may not serve as arbitrators.
B. An
enrollee may request arbitration of a surprise out‑of‑network bill and a health care services organization or health care provider may
request arbitration of a balance bill by submitting a request for
arbitration to the department on a form prescribed by the department, which
shall include contact, billing and payment information regarding the surprise
out‑of‑network bill or balance bill and any
other information the department believes is necessary to confirm that the bill
qualifies for arbitration. The form shall be made available on the
department's website.
C. Within
fifteen days after receipt of a request for arbitration, the department shall
do one of the following:
1. Determine
that the surprise out-of-network bill or balance bill qualifies
for arbitration under this article, and
notify the enrollee, health insurer or
health care services organization and health care provider that the
request qualifies, and for a surprise out‑of‑network
bill, also notify the enrollee.
2. Determine
that the surprise out-of-network bill or balance bill does
not qualify for arbitration under this article and notify the enrollee
affected parties that the surprise
out-of-network bill does not qualify and state the reason for the
determination.
3. If
the department cannot determine whether the surprise out‑of‑network
bill or balance bill qualifies for arbitration, request
in writing any additional information from the enrollee, health insurer, health care services organization or health care provider or
its billing company that is needed to determine whether the surprise
out‑of‑network bill qualifies for arbitration and all of the
following apply:
(a) The
enrollee, health insurer, health care services organization
or health care provider or its billing company shall respond to the
department's request for additional information within fifteen days after the
date of the department's request.
(b) Within
seven days after receipt of the additional requested information, the
department shall determine whether the surprise out‑of‑network
bill qualifies for arbitration and send the notices required under this
subsection.
(c) If
the health insurer, health care services organization or
health care provider or its billing company fails to respond within the time
frame specified in subdivision (a) of this paragraph to a department
request for information, the department shall deem the request for arbitration
as eligible for arbitration. If the enrollee fails to respond within
the time frame specified in subdivision (a) of this paragraph, the request for
arbitration of a surprise out‑of‑network bill is
denied.
D. The
determination by the department of whether a surprise out‑of‑network
bill or balance bill qualifies for arbitration is a final
and binding decision with no right of appeal to the department. The
department's determination is solely an administrative remedy and does not bar
any private right or cause of action for or on behalf of any enrollee, health care provider or other person. The court
shall decide the matter, including any interpretation of statute or rule,
without deference to any previous determination that may have been made on the
question by the department.
E. In
an effort to settle the surprise out‑of‑network bill or balance bill before arbitration, the department shall
arrange an informal settlement teleconference within thirty days after the
department sends the notices required by this section. The department is not a
party to and may not participate in the informal settlement
teleconference. As part of the settlement teleconference for a surprise out‑of‑network bill the health
insurer shall provide to the parties the enrollee's cost sharing requirements
under the enrollee's health plan based on the adjudicated claim.
The health insurer or health care services
organization shall notify the department whether the informal settlement
teleconference resulted in settlement of the disputed surprise out‑of‑network
bill or balance bill and, if settlement was reached,
notify the department of the terms of the settlement within seven days.
F. If
after proper notice from the department or contracted entity either the health
insurer or health care services organization or health
care provider or the provider's representative fails to participate in the
teleconference, the other party may notify the department to immediately
initiate arbitration and the nonparticipating party shall be required to pay
the total cost of the arbitration.
G. On
receipt of notice that the dispute has not settled or that a party has failed
to participate in the teleconference, the department shall appoint an
arbitrator and shall notify the parties of the arbitration and the appointed
arbitrator. The department's notice shall specify whether one party
is responsible for the total cost of the arbitration pursuant to subsection F
of this section. The health insurer or health care services
organization and health care provider must agree on the arbitrator and
may mutually agree to use an arbitrator who is not on the department's
list. If either the health insurer or health care
services organization or health care provider objects to the arbitrator,
and the parties are unable to agree on a mutually acceptable alternative
arbitrator, the department or contracted entity shall randomly assign three
arbitrators. The health insurer or health care services
organization and the health care provider shall each strike one arbitrator,
and the last arbitrator shall conduct the arbitration unless there are two
arbitrators remaining, in which case the department or contracted entity shall
randomly assign the arbitrator.
H. Before
the arbitration of a surprise out‑of‑network bill:
1. The
enrollee shall pay or make arrangements in writing to pay the health care
provider the total amount of the enrollee's cost sharing requirements that is
due for the health care services that are the subject of the surprise out‑of‑network
bill as stated by the health insurer in the settlement teleconference.
2. The
enrollee shall pay any amount that has been received by the enrollee from the
enrollee's health insurer as payment for the out‑of‑network health
care services that were provided by the health care provider.
3. If
a health insurer pays for out‑of‑network health care services
directly to a health care provider, the health insurer that has not remitted
its payment for the out‑of‑network health care services shall remit
the amount due to the health care provider.
I. Arbitration
of any surprise out‑of‑network bill or balance bill shall
be conducted telephonically unless otherwise agreed by all of the required
participants.
J. Arbitration
of the surprise out‑of‑network bill shall take place with or
without the enrollee's participation.
K. An
enrollee is not a party to any balance bill dispute between a health care
services organization and a health care provider. both the health care
services organization and the health care provider shall hold the enrollee
harmless for the balance bill amount.
K. L. The
arbitrator shall determine the amount the health care provider is entitled to
receive as payment for the health care services. The arbitrator shall allow
each party to provide information the arbitrator reasonably determines to be
relevant in evaluating the surprise out‑of‑network bill or balance bill, including the following information:
1. The
average contracted amount that the health insurer or health care
services organization pays for the health care services at issue in the
county where the health care services were performed.
2. The
average amount that the health care provider has contracted to accept for the
health care services at issue in the county where the services were performed.
3. The
amount that medicare and medicaid pay for the health care services at issue.
4. The
health care provider's direct pay rate for the health care services at issue,
if any, under section 32‑3216.
5. Any
information that would be evaluated in determining whether a fee is reasonable
under title 32 and not excessive for the health care services at issue,
including the usual and customary charges for the health care services at issue
performed by a health care provider in the same or similar specialty and
provided in the same geographic area.
6. Any
other reliable databases or sources of information on the amount paid for the
health care services at issue in the county where the services were performed.
L. M. Except
on the agreement of the parties participating in the arbitration, the
arbitration shall be conducted within one hundred twenty days after the
department's notice of arbitration.
M. N. Except
on the agreement of the parties participating in the arbitration, the
arbitration may not last more than four hours.
N. O. The
arbitrator shall issue a final written decision within ten business days
following the arbitration hearing. The arbitrator shall provide a copy of the
decision to the enrollee, the health insurer and the
health care provider or its billing company or authorized representative, and if the dispute is related to a surprise out‑of‑network
bill, provide a copy to the enrollee.
O. P. All
pricing information provided by health insurers, health care
services organizations and health care providers in connection with the
arbitration of a surprise out‑of‑network bill or
balance bill is confidential and may not be disclosed by the arbitrator
or any other party participating in the arbitration or used by anyone, other
than the providing party, for any purpose other than to resolve the surprise
out‑of‑network bill.
P. Q. All
information received by the department or contracted entity in connection with
an arbitration is confidential and may not be disclosed by the department or
contracted entity to any person other than the arbitrator.
Q. R. A
claim that is the subject of an arbitration request is not subject to article 1
of this chapter during the pendency of the arbitration. If not
already paid, a health insurer or health care services
organization shall remit its portion of the payment resulting from the
informal settlement teleconference or the amount awarded by the arbitrator
within thirty days after resolution of the claim. If the health
care services organization has already paid the health care provider more than
the amount awarded, the health care provider shall refund any overpayment within
thirty days after resolution of the claim.
R. S. A
claim that is reprocessed by an a health insurer or health care services
organization as a result of a settlement, arbitration decision or other
action under this article is not in violation of section 20‑3102,
subsection L.
S. T. Notwithstanding
any informal settlement or the arbitrator's decision under this article, the
enrollee is responsible for only the amount of the enrollee's cost sharing
requirements and any amount received by the enrollee from the enrollee's health
insurer as payment for the out‑of‑network health care services that
were provided by the health care provider, and the health care provider may not
issue, either directly or through its billing company, any additional balance
bill to the enrollee related to the health care service that was the subject of
the informal settlement teleconference or arbitration.
T. U. Unless
all the parties otherwise agree or unless required by subsection F of this
section, the health insurer or health care services organization
and the health care provider shall share the costs of the arbitration equally,
and the enrollee is not responsible for any portion of the cost of the
arbitration. The health insurer or health care
services organization and health care provider shall make payment
arrangements with the arbitrator for their respective share of the costs of the
arbitration." END_STATUTE
Renumber to
conform
Amend title
to conform
Bill
Number: S.B. 1024