Under WAC 284-43B-040, all carriers must have a process that helps providers and facilities determine if their patient is enrolled in a health plan that is subject to the Washington state Balance Billing Protection Act (BBPA). This page outlines the usage of two HIPAA EDI transactions that support this process. This information was previously hosted on the OneHealthPort website and has been transitioned to the Office of the Insurance Commissioner’s website.
To support this process, two HIPAA EDI transactions (5010 version) - "Final Rule" are used:
- X12 271 transaction - WAC 284-43B-040
- X12 835 transaction - WAC 284-43B-040
X12 271 transaction
The Balance Billing Protection Act (BBPA) requires that health care providers have a way to determine whether a patient's health insurance plan is subject to the requirement of the Act.
The below instructions describe the usage of the X12 5010 version of the 271 Eligibility and Benefits Response Transaction to implement RCW 48.49.020, to communicate that a patient's health insurance plan is subject to the requirements of the Act.
The most appropriate of the following messages is to be placed in the 271 transaction:
- "Services provided to this patient are subject to the Balance Billing Protection Act. Please see RCW 48.49.020 for details."
- "Services provided to this patient are subject to the No Surprises Act. Please see RCW 48.49.020 for details."
The placement of the message within the 271 transaction is as follows:
a. In an existing:
- Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION, OR
- Loop 2110D - DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION
b. For the EB segment where EB01=1,2,3,4,5,6,7,8 (active or inactive coverage)
Place the message in the MSG segment
Example:
- EB*1*IND*30*PR*THIS IS THE PLAN NAME~
- MSG* Services provided to this patient are subject to the Balance Billing Protection Act. Please see RCW 48.49.020 for details~
Note to providers: There is a limit of 10 messages per each 2110 Loop. If this message causes the health plan to have more than 10 messages, a separate Loop for the message may be created.
X12 835 transaction
The Balance Billing Protection Act (BBPA) requires that health care providers have a way to determine whether a patient's health insurance plan is subject to the requirement of the Act.
Beginning Jan. 1, 2023, the below instructions describe the usage of the X12 5010 version of the 837 Claims Transaction to implement RCW 48.49.020, to communicate that a patient's health insurance plan is subject to the requirements of the Act.
When using the 835 transaction to report the processing of a balance bill claim,
- Report RARC N830 as it provides the most complete explanation of the Balance Billing Requirements for both state and federal legislation,
- To the extent that other X12 RARC code(s) can provide additional specificity, they should also be reported.
Example:
- To communicate that Washington State’s Balance Bill Protection Act (BBPA) or the No Surprises Act (NSA) applies, then N858 should be reported for BBPA applicability and N859 should be reported for NSA applicability.
- To communicate more specific information about the processing of the claim so that the provider can take a specific action, AND that processing situation is accurately described by an existing State or No Surprise Act (NSA) balance billing related RARC, then that RARC should be reported.
The recommendation is subject to revision after a 90-day implementation period.