How to submit an arbitration request form (Appendix A)
A health care provider, facility or health insurer can submit this Arbitration Initiation Request Form (AIRF) if the following is true:
- You are submitting this on behalf of a carrier, provider, or facility initiating arbitration under the Balance Billing Protection Act (BBPA).
- The AIRF is submitted no later than 10 calendar days following the completion of the period of good faith negotiation.
- The most recent payment for the service in dispute was in the last 40 days.
- The patient’s plan is regulated by the Office of the Insurance Commissioner (OIC) or is a self-funded group health plan that has elected to participate in the BBPA.
- The email address for the non-initiating party you are providing for the other party has been verified and is correct - Health plan arbitration contact information.
- You are not submitting any identifiable patient information with the AIRF.
- You have read all the instructions on this page, including the notice requirements to the non-initiating party.
Steps to initiate arbitration
- Complete and submit the arbitration initiation request form
- Email a copy of the confirmation page to the non-initiating party. Both of these steps must be completed by the initiating party.
Each submission is a distinct arbitration proceeding
After you have gone through the screening steps and provided basic information about the parties, you will be asked to describe the health care services at issue and to complete the health care provider’s information. This information must be completed for each claim.
How to bundle claims into a single arbitration proceeding
Claims can be bundled in a single arbitration request. You may bundle up to 20 claims in a single filing if all the claims involve the same carrier and provider or facility, all have the same procedural code (or a comparable code under a different procedural system) and all occur within the same 30 business day period.
To submit bundled claims, select the number of claims being bundled on the health care provider information screen. The required information must be submitted for each claim. The form will not allow you to complete your submission without the required information for each claim. No additional documents can be uploaded.
How to print the confirmation page and send notice to the other party
The law requires that any information submitted to the OIC with the arbitration initiation request must be included in the notice to the non-initiating party. The party initiating the arbitration must provide written notification to the non-initiating party. To ensure that the non-initiating party receives all necessary information, OIC strongly encourages the initiating party to send a copy of the confirmation page (a copy of their completed arbitration initiation request form) to the non-initiating party’s verified email address to meet the notification requirement.
To print the completed AIRF, select the “Submit” button. The completed form will display a confirmation screen. You will need to print this as a .PDF document. On most systems, this is done by right-clicking with your cursor and selecting “Print…” and then printing as .PDF. If your system does not have this capability, you may also take screenshots and save them as .JPEG or .GIF images that would be attached to the email notification to the non-initiating party.
IMPORTANT: Do not exit out of the confirmation page before you have printed it. Once it has been closed, you will not be able to return to the confirmation page and will need to resubmit your AIRF.
OIC encourages the initiating party to send electronic notification to the non-initiating party shortly after submission of the AIRF to OIC.
DO NOT copy the OIC BBPA arbitration team on the email notification to the non-initiating party. If the non-initiating other party claims they did not receive timely notice from you, they can raise that issue with the arbitrator at which time you will be required to show proof that timely notice was sent.
What happens next
Within seven calendar days, the OIC BBPA arbitration team (through the OIC Administrative Hearings Unit) will conduct a review of your arbitration initiation request form and contact you. If your request was timely submitted and complete, the OIC will provide both parties with a unique number or designation for your arbitration initiation request (“AIRF Number”) as well as a link to the list of approved arbitrators or entities providing arbitration services.
The parties must include the AIRF number in all communication related to that request. A party seeking to challenge whether a claim is eligible, appropriately bundled, etc., may raise those issues during arbitration.
Once that notification to the parties has been sent from the OIC BBPA Arbitration Team, the parties have 5 calendar days to notify the OIC of their selection of the arbitrator or to request a narrowed list of 5 arbitrators. If the parties still cannot agree, one will be assigned by the OIC from the narrowed list.
Learn more about the BBPA arbitrator Arbitration selection process and the parties’ nondisclosure agreement.
Within ten business days of a party notifying OIC and the non-initiating party of the intent to initiate arbitration, both parties must agree to and execute a nondisclosure agreement.
The timeframe for corrections and resubmissions
Except for typographical errors, any corrected AIRFs also must be submitted within 10 calendar days of the submission of the original request. A party that has submitted an untimely notice is permanently foreclosed from seeking arbitration related to the claim or claims that were the subject of the untimely notice.
Do you have an accessibility or accommodation request?
The law requires that this form be submitted electronically through the OIC’s website. If you have a disability and require assistance or accommodation, please contact the OIC BBPA arbitration team.
To learn more about the Balance Billing Arbitration Act and arbitration process.