Balance billing and surprise billing protections
Customize your policy alerts
Sign up for all Washington Office of the Insurance Commissioner policy alerts
Know when Washington Office of the Insurance Commissioner releases new policies or updates existing guidance.
Monitor payer policy activity
Describes protections against balance (surprise) billing for Washington residents receiving emergency care or care from out-of-network providers at in-network hospitals or outpatient surgical centers; informs patients of their rights and plan/provider obligations.
No material clinical or coverage changes in this revision.
Balance Billing Protections & Coverage Rules
Balance billing protections and obligations
Protections and coverage rules for balance billing and surprise billing in Washington:
ALL of the following
Emergency services
- When a subscriber receives emergency services from an out-of-network provider or facility (including ground or air ambulance and behavioral health crisis services), the provider or facility may not bill the subscriber more than the plan's in-network cost-sharing amounts (deductible and coinsurance). Balance billing for these emergency services is prohibited.
In‑network facility, out‑of‑network provider
- When a subscriber receives certain services at an in‑network hospital or outpatient surgical facility from a provider who is not in‑network, that provider may not bill the subscriber more than the plan's in‑network cost‑sharing amounts.
Plan and provider obligations
- Plans must not require prior authorization for emergency services and must cover emergency services provided by out‑of‑network providers.
- The amount a subscriber owes must be based on the in‑network amount; plans must display the in‑network‑based amount in the explanation of benefits and count payments toward deductibles and out‑of‑pocket limits.
Dispute resolution and complaints
- If there is a dispute about a bill, subscribers may file a federal complaint via CMS (https://www.cms.gov/nosurprises or 1-800-985-3059) or contact the Washington Office of the Insurance Commissioner (1-800-562-6900).
Cost-sharing, Patient Responsibility, and Coding Notes
| No codes listed |
Provider Requirements and Operational Rules
Do not require prior authorization for emergency services; cover out-of-network emergency care
Plans may not require prior authorization for emergency services and must cover emergency services provided by out-of-network providers. The member is only responsible for the plan's in-network cost-sharing amounts (deductible, copay, coinsurance) for those emergency services, and the plan must display that in the explanation of benefits and apply payments toward deductibles and out-of-pocket limits.
- Plans must not require prior authorization for emergency medical services.
- Plans must cover emergency services provided by out-of-network providers.
- Member financial responsibility for emergency services is limited to in-network cost-sharing amounts and must be shown on the explanation of benefits.
- Payments for emergency services (including out-of-network emergency services) must count toward the member’s deductible and out-of-pocket limits.
Key Terms
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.