Protections Against Balance (Surprise) Billing
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Explains protections against balance (surprise) billing for consumers receiving emergency care or out-of-network services at hospitals and ambulatory surgical centers in Washington; describes when providers may bill more and consumer rights. Affects plan members and health care providers interacting with Washington health plans.
No material clinical or coverage changes in this revision.
Balance Billing Coverage Criteria
Balance billing coverage criteria
Stance on balance billing and member financial responsibility
ALL of the following
- This includes ground and air ambulance transport and hospital services provided to people experiencing a medical emergency.
ALL of the following
- Members pay only their share (deductible, copay, coinsurance) when balance billing is prohibited; plans should make payments to out‑of‑network providers as appropriate.
Member Liability and Coding Notes
| No codes listed |
Provider Billing Rules and Restrictions
Balance billing permitted from out-of-network providers
Out-of-network providers may seek payment from members for the difference between the provider’s charge and the plan’s payment (balance billing) when the provider is not contracted with the member’s plan.
- Also called “surprise billing”; occurs when receiving care from providers or facilities not contracted with the member’s plan.
- This extra amount can exceed in-network cost-sharing and is separate from applicable in-network deductible, copay, or coinsurance.
Emergency services cannot be balance billed; member cost-sharing limited to in‑network amounts
Emergency services provided by out-of-network providers or facilities cannot be balance billed; members may only be charged the plan’s in-network cost-sharing amounts (for example, applicable copayments, deductibles, and coinsurance).
- Includes ground and air ambulance services and emergency care received at hospitals or other facilities treating people with emergency medical conditions.
- Providers/facilities may not increase charges for emergency services beyond the member’s in-network cost-sharing obligations.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.