If a medical provider, ground ambulance provider or facility does not contract with a health plan but provides an enrollee with emergency services (including behavioral health emergencies) or services at an in-network facility, they must bill the health plan directly and not the enrollee. This includes behavioral health services provided by a:
- Mobile rapid response crisis team
- Crisis triage or stabilization facility
- Evaluation and treatment facility
- Or from an agency certified to provide outpatient crisis services or medical withdrawal management services vist the
The enrollee’s cost-sharing amount is limited to what it would be if the provider or facility was in the health plan’s network. Cost-sharing paid by the consumer also counts towards their deductible.
State and federal surprise billing laws apply to all health plans
Surprise billing protections apply to all state-regulated health plans, state and school employee benefit plans and self-funded group health plans. Some self-funded group health plans have also opted to follow Washington’s Balance Billing Protection Act and provide greater protections to their enrollees. All health insurers must have a process that helps a provider or facility determine if their enrollee is subject to Washington’s Balance Billing Protection Billing law.
How is the allowed billed amount determined?
The amount a provider or facility is paid under the Balance Billing Protection Act must be a commercially reasonable amount and based on payments for the same or similar services in a similar geographic area.
If the health plan and provider or facility cannot agree on an amount to be paid for the service after 30 days, either party can go to arbitration. Each party pays their own attorney fees and they split the cost of arbitration. The arbitrator will choose one party's best offer.
The parties can access a data set from the all payer claims database to help during the negotiation of a reasonable payment amount. Arbitrators also can access the data set to inform their decisions. The data set is based on commercial health insurance claims and includes the median in-network, out-of-network and billed charges for services covered under law.
- Explore claim payments in the All Payer Claims Database and learn about the arbitration process.
- See a list of approved arbitrators.
Consumer notice requirements for providers and facilities
Medical providers, facilities, and behavioral health emergency service providers must use this consumer notice through December 31, 2024, to meet their obligations under WAC-284-43B-050, including posting the notice on their on their website and providing it to consumers, if asked. They also must:
- Refund consumers any amount they have overpaid within 30 business days.
Not ask consumers to limit or give up their rights to prevent balance billing.
Effective January 1, 2025, ground ambulance services are included in the Balance Billing Protection Act. The updated consumer notice (PDF, 205.78 KB) must be used beginning January 1, 2025. For translated consumer notifications in twelve languages please visit the What consumers need to know about surprise billing webpage.
Medical facilities must:
Give health insurers they contract with a list of non-employed providers under contract with the facility that provide surgical or ancillary services within 30 days of signing a contract with a health insurer.
Notify the health insurer within 30 days of a provider’s removal from or addition to the non-employed provider list.
Respond to a health insurer’s request for an updated provider list within 14 days.
And medical providers must give accurate and timely information to health insurers about their status in the plan’s network.
How enforcement works
If a provider or facility continues to balance bill a consumer and we see a pattern of unresolved violations of the Balance Billing Protection Act, we will first give the provider or facility a chance to correct its behavior.
If no steps are taken by the provider or facility to correct the balance billing, we will consider it unprofessional conduct and will refer the provider or facility to the Department of Health for enforcement.