ARIZONA HOUSE OF REPRESENTATIVES Fifty-seventh Legislature First Regular Session

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HB 2130: claims; prior authorization; denials; contact

Sponsor: Representative Bliss, LD 1

Committee on Health & Human Services

Overview

Requires a health care insurer that denies a claim or prior authorization for any reason to provide both a detailed explanation as to why a claim or prior authorization was denied and the contact information of the individual or specific department that can address questions about the claim or prior authorization denial.

History

Health care insurer means a disability insurer, group disability insurer, blanket disability insurer, health care services organization, prepaid dental plan organization, hospital service corporation, medical service corporation, dental service corporation, optometric service corporation or hospital, medical, dental and optometric service corporation. Clean claims are written or electronic claims for health care services or benefits that may be processed without obtaining additional information, including coordination of benefits information, from the health care provider, the enrollee or a third party, except in fraud cases (A.R.S. § 20-3101).

Statute outlines the process for timely payment of health care provider's claims and to address grievances. Specifically, health care insurers must adjudicate any clean claim from a contracted or noncontracted health care provider relating to health care insurance coverage within 30 days after the health care insurer receives the clean claim or within the time specified by the contract. If the claim is not a clean claim and the health care insurer requires additional information to adjudicate the claim, the health care insurer must send a written request for additional information to the contracted or noncontracted health care provider, enrollee or third party within 30 days after the health care insurer receives the claim.

A health care insurer must not delay the payment of clean claims to a contracted or noncontracted provider or pay less than the amount agreed to by contract to a contracted health care provider without reasonable justification (A.R.S. § 20-3102).

Provisions

1. Requires a health care insurer, if a claim or prior authorization is denied for any reason, to provide both:

a) a detailed explanation as to why the claim or prior authorization was denied; and

b) the name and contact information of an individual or specific department of the insurer that can address questions about the claim or prior authorization denial.     (Sec. 1)

c)

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