Get Az Surprise Out-of-network Billing Dispute Resolution (soonbdr) Request 2019-2025

This guide provides clear and supportive instructions for users to successfully fill out the Arizona Surprise Out-of-Network Billing Dispute Resolution (SOONBDR) Request online. By following these steps, users can navigate the form efficiently and ensure that their dispute resolution request is properly submitted.

Follow the steps to fill out the SOONBDR Request online.

1. Press the ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the enrollee information. This includes the first name, middle name, last name, suffix, email address, phone number, and mailing address. Ensure all details are accurate and clearly written.
3. Provide insurance coverage information as it appears on the insurance card, including the name of the insurance company, the member ID number, and the group number.
4. Fill out patient information, specifying if it is the same as the enrollee. If not, provide the patient's first name, middle name, last name, suffix, date of birth, and relationship to the enrollee.
5. Complete the healthcare provider details, providing the name, business name (if applicable), billing address, email address, city, state, ZIP code, and phone number of the healthcare provider.
6. In the bill details section, input information regarding the healthcare services provided. Include the date of service, the total billed amount, required copayment, coinsurance, and the remaining deductible before this bill.
7. Answer the additional eligibility questions honestly. Depending on the responses, you may need to provide additional documentation.
8. If applicable, fill out the authorized representative information if someone is completing the form on behalf of the enrollee. Ensure that authorization is clearly indicated.
9. Review the dispute resolution request checklist and ensure that you have clear photocopies of all essential and helpful documents ready to be submitted with the request.
10. Finalize the form by signing the attestation and indicating the date. Make sure all information is accurate before submitting.
11. Submit the completed dispute resolution request form online and save any changes made. You may also download, print, or share the form for your records.

Complete your documents online today to ensure your dispute is addressed promptly.