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ARIZONA STATE SENATE
Fifty-Sixth Legislature, Second Regular Session
grievance process; payment methods; report
Purpose
Establishes reporting requirements for health insurance grievances and prescribes health insurer billing requirements.
Background
Statute governs contracts between providers and insurers and prescribes payment and notification requirements for payments made by providers to insurers. Any contract issued, amended or renewed beginning January 1, 2020, may not restrict the payment method to only credit card transactions. If an insurer opts for electronic funds transfer payments, the insurer must inform providers of the associated fees, provide alternative payment options and include explanations of benefits with each payment. An insurer that initiates or changes payment with a provider using electronic funds transfer may not charge fees solely for transmitting payments to providers unless the provider consents (A.R.S § 20-241).
Statute requires health care insurers to establish internal systems for resolving payment disputes and other contractual grievances with health care providers, subject to review by the Director of the Department of Insurance and Financial Institutions (DIFI). Insurers must maintain records of provider grievances and provide DIFI with a semiannual summary of grievances received in the prior six months. Records must include: 1) the name and identification number of any provider who filed a grievance; 2) the type of grievance; 3) the date of receipt of the grievance; and 4) the date of resolution (A.R.S. § 20-3102).
A grievance is any written complaint that is subject to resolution through an insurer's system, submitted by a health care provider and received by a health care insurer. Grievance does not include any complaint: 1) by a noncontracted provider regarding an insurer's decision to deny the admission to the insurer's network; 2) about an insurer's decision to terminate a health care provider from the insurer's network; or 3) that is the subject of a health care appeal (A.R.S. § 20-3101).
There is no anticipated fiscal impact to the state General Fund associated with this legislation.
Provisions
1. Requires health insurers to accept tangible checks as a form of payment.
2. Stipulates that, if a health care provider opts out of a method of payment, that decision remains in effect until either the provider opts back in to the prior payment method or a new contract is executed between the insurer and provider.
3. Includes, in the definition of insurance grievance any delay in the timeliness of claim adjudication that results in a delay of payment or a clean claim.
4. Requires the Director of DIFI, by August 1 of each year, to post a report on DIFI's public website that includes the information on grievances for the prior fiscal year, including the:
a) total number of grievances received;
b) average time to resolve a grievance; and
c) percentage of grievances where a health care insurer's decision was overturned.
5. Specifies that statutes related to payment of insurance claims do not preclude a health care provider, with written informed consent of a patient, from collecting monies for a medical service that is either:
a) not covered under the insurance policy; or
b) medically necessary and a payment on the claim was not made due to a denial or disallowance based on frequency, with rates limited to the rates prescribed by the provider's fee schedule.
6. Makes technical and conforming changes.
7. Becomes effective on the general effective date.
House Action
HHS 2/12/24 DPA 9-0-0-1
3rd Read 2/22/24 57-0-2-0-1
Prepared by Senate Research
March 8, 2024
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