Ariz. Admin. Code § 20-6-2406

Current through Register Vol. 30, No. 50, December 13, 2024

Section R20-6-2406 - The Arbitration

A. Conduct of Arbitration. An Arbitration of a qualifying out-of-network surprise bill shall be conducted:

1. Telephonically unless the parties agree otherwise;

2. With or without the enrollee's participation;

3. Within 120 days after the Department's Notice of Arbitration unless agreed otherwise by the parties; and

4. For a maximum duration of four hours unless agreed otherwise by the parties.

B. Arbitrator's Determination. The Arbitrator or Alternative Arbitrator shall determine the amount the health care provider is entitled to receive as payment for the health care services that are the subject of the qualifying surprise out-of-network bill.

C. Allowable Evidence. The Arbitrator or Alternative Arbitrator shall allow each party to provide relevant information for evaluating the qualifying surprise out-of-network bill including:

1. The average contracted amount that the health insurer pays for the health care services at issue in the county where the health care provider performed the health care services;

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 health care provider performed the services;

3. The amount 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 A.R.S. § 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; and

6. Any other reliable sources of information, including databases, that provide the amount paid for the health care services at issue in the county where the health care provider performed the services.

D. Final Written Decision. Within 10 business days following the Arbitration, the Arbitrator or Alternative Arbitrator shall issue a Final Written Decision and provide a copy to the enrollee, the health insurer, the health care provider, the health care provider's billing company (if applicable) and the health care provider's authorized representative (if applicable).

E. Payment of the claim. The health insurer shall remit its portion of the payment awarded by the Arbitrator or Alternative Arbitrator to the health care provider within 30 days of the date of the Final Written Decision. A claim that is reprocessed by a health insurer as a result of the Arbitration is not in violation of A.R.S. § 20-3102(L).

F. Payment of the Costs of Arbitration. The health insurer and health care provider shall make payment arrangements with the Arbitrator or Alternative Arbitrator to pay their respective shares of the costs of the Arbitration within 30 days after the date of the Final Written Decision. The respective shares of the costs of Arbitration are determined as follows:

1. The enrollee is not responsible for any portion of the cost of the Arbitration.

2. The health insurer and the health care provider shall share the costs of the Arbitration equally unless one of the following exceptions applies:

a. The health insurer and health care provider agree to share the costs of the Arbitration in non-equal portions.

b. The health insurer pays the entire cost of the Arbitration for failing to participate in the Informal Settlement Teleconference after receiving proper notice from the Department.

c. The health care provider or the health care provider's representative pays the entire cost of the Arbitration for failing to participate in the Informal Settlement Teleconference after receiving proper notice from the Department.

G. Confidentiality. In connection with the Arbitration of a qualifying surprise out-of-network bill, all of the following apply:

1. All pricing information provided by a health insurer or health care provider is confidential.

2. Pricing information provided by a health insurer or health care provider may not be disclosed by the Arbitrator, Alternative Arbitrator or any other party participating in the Arbitration.

3. Pricing information provided by a health insurer or health care provider may not be used by anyone, except the party providing the information, for any purpose other than to resolve the qualifying surprise out-of-network bill.

4. All information received by the Department in connection with the Arbitration is confidential and may not be disclosed to any person except the Arbitrator or Alternative Arbitrator.

H. Arbitrator's Report. At the conclusion of each Arbitration, the Arbitrator shall produce a report to the Department that contains the following information:

1. Date of Arbitration;

2. Date the Arbitrator issued the Final Written Decision;

3. Whether the parties settled the qualifying surprise out-of-network bill during the Arbitration;

4. The initial amount billed by the health care provider;

5. The payment amount awarded to the health care provider; and

6. Any other information the Department may request an Arbitrator to report prior to an Arbitration.

Ariz. Admin. Code § R20-6-2406

New Section made by exempt rulemaking at 25 A.A.R. 155, effective 1/2/2019.