This page outlines the usage of two Health Insurance Portability and Accountability Act Electronic Data Interchange (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

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 Act's requirements.

The instructions below 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 Act's requirements.

For those coverage plans that are subject to the BBPA, the following message is to be placed in the 271 transaction:

BBPA/NSA Message: Emergency, air ambulance, and nonemergency services provided by an Out-of-Network provider at an in-network hospital or ASC are subject to the BBPA or NSA.  Ground ambulance services are subject to the BBPA. Please see RCW 48.49.020 & RCW 48.49.200 for details.

 

  For patient as subscriber:
      Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION, EB Segment
      EB01 = D
  For patient as a dependent:
      Loop 2110D - DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION, EB Segment
      EB01 = D 

 

Example:

  • EB*D***********N~
  • MSG* Emergency, air ambulance, and nonemergency services provided by an Out-of-Network provider at an in-network hospital or ASC are subject to the BBPA or NSA.  Ground ambulance services are subject to the BBPA. Please see RCW 48.49.020 & RCW 48.49.200 for details.

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 Act's requirements.

Beginning Jan. 1, 2023, the instructions below 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 Act's requirements. 

When using the 835 transaction to report the processing of a balance bill claim,

  • Report Remittance Advice Remark Code (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 codes can provide additional specificity, they should also be reported.

Example:

  • To communicate that the BBPA or the No Surprises Act (NSA) applies, N858 should be reported for BBPA applicability and N859 should be reported for NSA applicability. 
  • To communicate more specific information about claim processing so that the provider can take a specific action, AND that processing situation is accurately described by an existing state or NSA balance billing-related RARC, that RARC should be reported.