Title 20 — Insurance

A. To qualify for renewal of a resident license: 1. If the license period immediately preceding the renewal commenced before January 1, 2014 and the licensee held a nonresident license in another state to transact insurance at any time during the license period, the licensee shal…

A. Licensees shall maintain their own continuing education records described in section 20-2902, subsection F and shall keep the records until the second renewal date after the period for which the continuing education credits were earned. B. In order to verify the attendance and…

A. Pursuant to title 41, chapter 23, the director shall enter into a contract with a person for the approval of approved providers and courses and administration of the continuing education program. B. The contractor shall: 1. Accept or reject provider organizations as approved p…

In this article, unless the context otherwise requires: 1. "Adjudicate" means an insurer's decision to deny or pay a claim, in whole or in part, including the decision as to how much to pay. 2. "Clean claim" means a written or electronic claim for health care services or benefits…

A. A health care insurer shall adjudicate any clean claim from a contracted or noncontracted health care provider relating to health care insurance coverage within thirty days after the health care insurer receives the clean claim or within the time period specified by contract. …

(Eff. 7/1/26) Before a health care insurer may deny a claim that was submitted by a provider on the basis of medical necessity, the medical director shall individually review the denial. During each individual review, the medical director shall exercise independent medical judgme…

In this article, unless the context otherwise requires: 1. "Arbitration" means a dispute resolution process in which an impartial arbitrator determines the dollar amount a health care provider is entitled to receive for payment of a surprise out-of-network bill. 2. "Arbitrator" m…

This article does not apply to: 1. Health care services that are not covered by the enrollee's health plan. 2. Limited benefit coverage as defined in section 20-1137. 3. Charges for health care services that are subject to a direct payment agreement under section 32-3216 or 36-43…

A. A bill for a health care service that was provided in a network facility by a health care provider that is not a contracted provider must meet one of the following requirements to qualify as a surprise out-of-network bill: 1. The bill was for emergency services, including unde…

A. An enrollee who has received a surprise out-of-network bill and who disputes the amount of the bill may seek dispute resolution of the bill by filing a request for arbitration with the department not later than one year after the date of service noted in the surprise out-of-ne…

A. The department shall develop a simple, fair, efficient and cost-effective arbitration procedure for surprise out-of-network bill disputes and specify time frames, standards and other details of the arbitration proceeding, including procedures for scheduling and notifying the p…

To qualify as an arbitrator, a person shall have at least three years' experience in health care services claims and shall comply with any other qualifications established by the department.

A. The department in conjunction with the appropriate health care boards shall prescribe the notice outlining an enrollee's rights to dispute surprise out-of-network bills under this article. B. Health insurers shall include the notice prescribed pursuant to subsection A of this …

A. On or before December 31, 2019 and each December 31 thereafter, the department shall report on the resolution of disputed surprise out-of-network bills. The report shall include: 1. The total number of inquiries regarding dispute resolution of surprise out-of-network bills. 2.…

An enrollee who is aggrieved by an arbitration decision regarding a disputed surprise out-of-network bill may file a civil action in superior court not later than one year after the date of the disputed decision to obtain appropriate relief with respect to the same surprise out-o…

For the purposes of this section: 1. "Enrollee" means an individual who is enrolled in a health care plan provided by a health care insurer. 2. "Health care insurer" means a disability insurer, group disability insurer, blanket disability insurer, health care services organizatio…

A. This chapter does not create: 1. Any liability on the part of any employer or employer group purchasing organization that purchases coverage or assumes risk on behalf of its employees or on behalf of self-funded employee benefit plans. 2. Any new or additional liability on the…

A. A health care insurer is liable for any damages caused to the insurer's enrollee by the insurer's delay in authorizing or failure to authorize a request for medically necessary health care services covered under the health care plan or by the insurer's denial of payment of ben…

In an action under this chapter, any person, enrollee or health care insurer may introduce into evidence for any purpose any of the documents, findings, decisions or information concerning events that occurred in the health care appeals process pursuant to chapter 15, article 2 o…

A. Before an enrollee files an action pursuant to section 20-3153, the enrollee shall either: 1. Complete the health care appeals process prescribed in chapter 15, article 2 of this title. 2. Provide written notice to the health care insurer at least thirty days before filing sui…

1. "Advertising" means any written, electronic or printed communication or any communication by means of recorded telephone messages or transmitted by radio, television, the internet or similar communications media, including film strips, motion pictures and videos, that is publi…

A. Except as otherwise provided in this section, a person shall not act as a provider or broker with any owner who is a resident of this state unless the person obtains a certificate of authority or license pursuant to this section. B. An applicant for a provider certificate of a…

B. As a condition of responding to a request for verification of coverage or in connection with the transfer of a policy pursuant to a life settlement contract, an insurer may not require that the owner, insured, provider or broker sign any form, disclosure, consent, waiver or ac…

1. That there are possible alternatives to life settlements, including accelerated benefits options that may be offered by the life insurer or policy loans. 2. That some or all of the proceeds of a life settlement may be taxable and that assistance should be sought from a profess…

1. Necessary to effect a life settlement contract between the owner and a provider and the owner and insured have provided prior written consent to the disclosure. 2. Necessary to effect the sale of life settlement contracts or interests in life settlement contracts as investment…

B. The director, whenever the director deems it reasonably necessary to protect the interests of the public, may examine the business and affairs of any licensee or applicant for a license. The director may order any licensee or applicant to produce any records, books, files or o…

A. The director may investigate suspected fraudulent life settlement acts and persons engaged in the business of life settlements. B. After determining that an examination should be conducted, the director shall issue an examination warrant appointing one or more examiners to per…

A. The director may not appoint an examiner if the examiner, either directly or indirectly, has a conflict of interest or is affiliated with the management of or owns a pecuniary interest in any person subject to examination under this chapter. This section does not automatically…

A. The director, the director's authorized representatives or any examiner appointed by the director is not liable for any statements made or conduct performed in good faith while carrying out the provisions of this chapter. B. A person who communicates or delivers information or…

A. Each licensed provider shall file with the director on or before March 1 of each year an annual statement in a form prescribed by the director. The annual statement shall be verified by the oath of at least two of its principal officers, showing its condition at the end of the…

1. If the owner is the insured, a written statement from a licensed attending physician that the owner is of sound mind and under no constraint or undue influence to enter into a settlement contract. 2. A document in which the insured consents to the release of the insured's medi…

This chapter does not: 1. Preempt the authority or relieve the duty of other law enforcement or regulatory agencies to investigate, examine and prosecute suspected violations of law. 2. Prevent or prohibit a person from disclosing voluntarily information concerning life settlemen…

A. A provider lawfully transacting business in this state before the effective date of this chapter may continue to transact business in this state, pending approval or disapproval of that person's application for a license, if the provider files the application with the director…

A. In addition to the penalties and other enforcement provisions of this chapter, if any person violates any provision of this chapter or any rule adopted pursuant to this chapter, the director may seek an injunction in a court of competent jurisdiction in the county where the pe…

B. A person who commits a fraudulent life settlement act is guilty of committing insurance fraud and is subject to section 20-466.01. C. The director may seek an injunction and an order of restitution and may levy a civil penalty pursuant to section 20-466.02 on any person who is…

The interstate insurance product regulation compact is enacted into law as follows: Article I Purpose Under the terms and conditions of this compact, this state seeks to join with other states and establish the interstate insurance product regulation compact and thus become a mem…

A. In this article, unless the context otherwise requires: 1. "Insurance compliance audit" means a voluntary, internal evaluation, review, assessment, audit or investigation that follows adopted written standards and criteria for the purpose of identifying or preventing noncompli…

1. If any company, person or entity performs or directs the performance of an insurance compliance audit, an officer, employee or agent involved with the insurance compliance audit or any consultant who is hired for the purpose of performing the insurance compliance audit may not…

In this chapter, unless the context otherwise requires: 1. "Auditing entity" means any person, company, group or plan working on behalf of or pursuant to a contract with an insurer or pharmacy benefits manager for the purposes of auditing pharmacy drug claims adjudicated by pharm…

A. The following procedures apply to an audit conducted by an auditing entity: 1. When conducting an in-pharmacy audit an auditing entity shall: (a) Give a pharmacy at least fourteen days' written notice. (b) Not conduct an audit during the first five days of the month unless the…

A. The auditing entity must deliver a preliminary audit report to the pharmacy within sixty days after the conclusion of the audit. B. A pharmacy is allowed at least thirty days after receipt of the preliminary audit to provide documentation to address any discrepancy found in th…

A. Notwithstanding any other law, this article applies only to audits conducted of pharmacies located in this state. B. This article does not apply to claims reviews that are initiated within three business days after transmission of a claim in which no chargeback or recoupment i…

A. A pharmacy benefit manager shall do all of the following: 1. Update the price and drug information for each list that the pharmacy benefit manager maintains every seven business days. 2. At the beginning of the term of a contract, on renewal of a contract and at least once ann…

1. Adjudicating a pharmacy benefit claim. 2. Processing or transmitting a pharmacy benefit claim. 3. Developing or managing a claims processing or adjudication network. 4. Participating in a claims processing or adjudication network. B. A pharmacy may submit a complaint of a viol…

B. A pharmacy benefit manager that applies for a certificate of authority shall submit to the director both of the following: 1. An application in a form and manner prescribed by the director. An officer or individual who is responsible for the conduct of the activities of the ph…

B. The director shall not order the destruction or other disposal of any record, book, document or other data that is: 1. Required by law to be maintained. 2. Kept on file with the department until ten years have passed. 3. Filed during the director's administration or administra…

A. A pharmacy benefit manager that enters into an agreement with a health care insurer to provide pharmacy benefit management services to covered individuals on behalf of the pharmacy benefit manager or a health care insurer may not limit or exclude coverage of a prescription dru…

A. On renewal of a health care plan, a health care insurer, pharmacy benefit manager or utilization review agent shall provide a covered individual and prescribing health care provider with access to a clear and convenient process to request a formulary exception process. The hea…

1. "Drug coverage": (a) Means any form of compensation paid to a pharmacy that dispenses prescription drugs for a patient under a contractual or other legal obligation with a health insurer or pharmacy benefit manager. (b) Does not include either of the following: (i) Coverage pr…

B. This article does not apply to any of the following: 1. The Arizona health care cost containment system administration and its contractors as defined in section 36-2901 to the extent the services are provided pursuant to title 36, chapter 29 or 34 or equivalent medicaid progra…