HB 2290
Initials AG Page 1 Health & Human Services
ARIZONA HOUSE OF REPRESENTATIVES
Fifty-sixth Legislature
First Regular Session
HB 2290: insurance; claims; appeals; provider credentialing
Sponsor: Representative Cook, LD 7
Committee on Health & Human Services
Overview
Establishes procedures and timeframes for when a health care insurer denies a health care
services claim, in whole or in part.
History
A health care insurer includes a disability insurer, group disability insurer, blanket disability
insurer, health care services organization, hospital service corporation and a medical service
corporation, prepaid dental plan organization, dental service corporation or 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 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 health care insurers to provide the following information if they deny a health care
service claim in whole or in part:
a) an explanation of the denial;
b) the provider's right to appeal the health care insurer's decision;
c) the manner in which the provider may allow the health care insurer's decision, including
applicable deadlines;
d) the provider's right to request a hearing, if the appeal to the health care insurer is
unsuccessful; and
e) the manner in which the provider may request a hearing. (Sec. 1)
2. Specifies that for the denial explanation, if the denial is based on lack of medical necessity,
the health care insurer must provide detailed information as to why the health care service
was not medically necessary. (Sec. 1) HB 2290
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3. Allows a provider to appeal a health care insurer's decision to deny a claim and file a written
claim dispute with the insurer within 180 days after they receive the notice that the claim has
been denied. (Sec. 1)
4. Requires the claim dispute to specify the factual basis for the dispute and requested relief.
(Sec. 1)
5. Requires health care insurers to respond to the claim dispute in writing with their decision
within 30 days after receiving the written claim dispute unless the provider and insurer
mutually agree to a longer period of time. (Sec. 1)
6. Outlines what the health care insurers decision must include. (Sec. 1)
7. Requires health care insurers to remit payment for approved portions of a claim within 15 days
after the date of the health care insurer's decision if a claim is approved in whole or in part.
(Sec. 1)
8. Allows providers to submit a written request for a hearing to the Arizona Department of
Insurance and Financial Institutions (DIFI) and a copy of the request to the health care insurer
within 30 days after receiving the health care insurer's decision or the date on which the
provider should have received the health care insurer's decision if a claim dispute is denied.
(Sec. 1)
9. Requires DIFI to request a hearing with the Office of Administrative Hearings (OAH) if a
provider timely submits a hearing request. (Sec. 1)
10. Directs DIFI to send the Director's decision to the provider within 30 days after the date the
administrative law judge issues its recommended decision and order. (Sec. 1)
11. Specifies that if the provider decides to withdraw their request for a hearing, the provider must
send a written request for withdrawal to DIFI. (Sec. 1)
12. Requires DIFI to accept the written request for withdrawal if the request is received before
they request a hearing with OAH. (Sec. 1)
13. Specifies that if DIFI already submits a request for a hearing, the provider must promptly send
a written request for withdrawal to OAH. (Sec. 1)
14. Reduces the number of calendar days health care insurers must conclude the process of
credentialing and loading an applicant's information into the health insurer's billing system
from 100 to 45 calendar days after the date the health insurer receives a complete
credentialing application. (Sec. 3)
15. Requires health care insurers to provide written or electronic confirmation:
a) within two business days on receipt of a complete credentialing application; or
b) within seven business days on receipt of a credentialing application with deficiencies.
(Sec. 3)
16. Specifies that health care insurers must provide written or electronic notice of the approval or
denial of a complete credentialing application to an applicant within seven days after the
conclusion of the credentialing process. (Sec. 1)
17. Prohibits health insurers from denying a claim for a covered service provided to a subscriber
by a participating provider who has a fully executed contract with a network plan if the covered
services are provided after the date of submission of the complete credentialing application.
(Sec. 4) HB 2290
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18. Defines terms. (Sec. 1, 2)
19. Makes technical and conforming changes. (Sec. 2, 3)
☐ Prop 105 (45 votes) ☐ Prop 108 (40 votes) ☐ Emergency (40 votes) ☐ Fiscal Note