If a health plan’s enrollee is treated by an out-of-network provider for emergency services or at an in-network facility for scheduled services covered by the Balance Billing Protection Act (www.leg.wa.gov), the provider or facility that is out-of-network will submit a claim to the enrollee's health plan.
The amount the health insurer pays the facility or provider must be a “commercially reasonable amount” based on payments for the same or similar services in a similar geographic area. If the health plan and the facility or provider cannot agree on the amount, either party can start the arbitration process.
The law also requires health insurers to have a way to inform a provider or facility (www.onehealthport.com) if its enrollees are subject to the Balance Billing Protection Act. This process can take place when determining an enrollee's coverage eligibility.
How arbitration works
If the insurer and provider or facility cannot agree on a price for the service, either party can initiate arbitration. Each party pays their own attorney fees, and they split the cost of arbitration. The arbitrator will choose the best final offer from one party.
Parties will have access to a data set from the All Payer Claims Database that:
- Is based on commercial fee-for-service health insurance claims.
- Includes median in-network, out-of-network and billed charges for services covered under the Act.
What information insurers must share with enrollees
Insurers must post the notice of consumers’ surprise billing rights on their website and update their online provider directory within 30 days when a provider is added or terminated. Also, they must give enrollees:
- A clear description of the health plan's out-of-network benefits.
- If asked, an estimated range of out-of-pocket costs for an out-of-network service.
- What an enrollee's financial responsibility is if they get out-of-network services other than those protected from balance billing.
See the notice for consumers about their rights (PDF, 143KB) under the Balance Billing Protection Act.