Assigned to GOV FOR COMMITTEE
ARIZONA STATE SENATE
Fifty-Sixth Legislature, First Regular Session
FACT SHEET FOR H.B. 2290
claims; appeals; provider credentialing
Purpose
Establishes procedures for a health care insurer's denial of a health care services claim and
allows a health care provider (provider) to timely request a hearing with the Office of
Administrative Hearings (OAH), if the provider's claim denial grievance is unresolved.
Background
Statute allows a covered person's treating provider whose claim for a covered service is
denied to pursue the applicable review process. A health care insurer must provide at least the
following levels of review: 1) an expedited medical review and appeal; 2) an informal
reconsideration; 3) a formal appeal process; and 4) an external independent review (A.R.S.
§ 20-2533).
A health care insurer must establish, and the Director of the Department of Insurance and
Financial Institutions (DIFI) may review, an internal system for resolving payment disputes and
other contractual grievances with providers. Each health care insurer must maintain records of
provider grievances and semiannually provide the Director of DIFI with a summary of the records
received during the prior six months (A.R.S. § 20-3102).
A health insurer must establish a process for the electronic submission of a credentialing
application. Credentialing means to collect, verify and assess whether a provider meets relevant
licensing, education and training requirements to become or remain a participating provider. A
health insurer must conclude the process of credentialing and loading the applicant's information
into the health insurer's billing system within 100 calendar days after the date the insurer receives
a complete application, with certain exceptions. If covered services are provided after the date of
approval of a credentialing application, a health insurer may not deny a claim for a covered service
provided to a subscriber by a participating provider who has a fully executed contract with a
network plan (A.R.S. §§ 20-3451; 20-3452; and 20-3456).
The Joint Legislative Budget Committee fiscal note states that OAH estimates a $30,000
annual cost for administering 240 new health care services claim denial hearings annually as a
result of the expanded hearing requirements (JLBC fiscal note).
Provisions
Denial of Health Care Services Claim
1. Requires, upon the denial, in whole or in part, of a health care services claim, the health care
insurer to provide the provider with contact information that includes a telephone number and
email address for an individual who is able to respond to questions about the claim denial. FACT SHEET
H.B. 2290
Page 2
2. Requires a health care insurer, at the request of a provider, to provide the following information
to the provider within 15 days after receiving the request:
a) if a denial was based on lack of medical necessity, a detailed reason why the health care
service was not medically necessary and the provider's right to appeal pursuant to the
utilization review statutes;
b) if the health care plan is not subject to regulation by DIFI, a notification to the provider of
the appropriate regulatory authority; and
c) the provider's right to dispute the insurer's decision that includes:
i. the manner in which the provider may dispute the insurer's decision using the insurer's
internal grievance process, including applicable statutory deadlines; and
ii. the provider's right to request an OAH hearing if the internal grievance process with
the insurer is unresolved, including the manner in which the provider may request a
hearing.
3. Requires a health care insurer, within 30 days after receiving a written grievance, to respond
in writing with the insurer's decision, unless the provider and insurer mutually agree to a longer
time period.
4. Requires the health care insurer's decision regarding the grievance to include:
a) the date of the decision;
b) the factual and legal basis for the decision;
c) the provider's right to request an OAH hearing; and
d) the manner in which a provider may request an OAH hearing.
5. Requires a health care insurer that finds in favor of the provider to remit payment for the
approved portion of the claim within 15 days after the insurer's decision.
6. Subjects a health care insurer's establishment of an internal system for resolving payment
disputes and other contractual grievances with providers to the prescribed time periods for a
health care service claim denial.
Provider Claim Dispute Hearing
7. Allows a provider, if the provider's grievance is unresolved, to submit a written request for an
OAH hearing to DIFI within 30 days after receiving the insurer's decision, or the date the
provider should have received the insurer's decision and requires the provider to submit a copy
of the hearing request to the insurer.
8. Requires DIFI, if the provider timely submits a request for a hearing with DIFI, to request a
hearing within OAH.
9. Requires the provider to send a written request for withdrawal to DIFI if the provider decides
to withdraw the request for an OAH hearing.
10. Directs DIFI to accept the request for withdrawal if received before DIFI requests an OAH
hearing or requires the provider, if DIFI already submitted the request for an OAH hearing, to
promptly send a written request for withdrawal to OAH. FACT SHEET
H.B. 2290
Page 3
11. Prohibits, if a party to a decision seeks further administrative review, DIFI from being a party
to the action unless DIFI files a motion to intervene.
Health Insurer Credentialing
12. Reduces, from 100 calendar days to 45 calendar days, the time period after receiving a
complete credentialing application within which a health insurer must conclude the process of
credentialing and loading applicant information into the insurer's billing system.
13. Requires a health insurer 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.
14. Replaces the prohibition on a health insurer denying a covered service claim for services
provided after approval of a credentialing application with a requirement that the health insurer
must pay a claim for a covered service provided to a subscriber by a participating provider
whose credentialing application has been approved by the insurer retroactively to the date of
the provider's complete credentialing application.
Miscellaneous
15. Defines terms.
16. Makes technical and conforming changes.
17. Becomes effective on the general effective date.
House Action
HHS 2/13/23 DP 9-0-0-0
3
rd
Read 3/7/23 42-18-0
Prepared by Senate Research
March 27, 2023
MG/slp