Balance Billing Protection Act

This page outlines the usage of 2 HIPAA EDI transactions in support of Washington State's Balance Bill Protection Act (BBPA)

  1. Use of the X12 271 to be in compliance with the OIC's Final Rule - RCW 48.49.020
  2. Use of the X12 835 to be in compliance with a Best Practice Recommendation

 

1. Usage of X12 271 Transaction (5010 version) - "Final Rule"

The Balance Billing Protection Act requires that health care providers have a way to determine whether a patient's health insurance plan is subject to the requirement of the Act.

The below instructions describe the usage of the X12 5010 version of the 271 Eligibility and Benefits Response Transaction to implement section 7(4) of the Balance Billing Protection Act (Chapter 427, Laws of 2019), to communicate that a patient's health insurance plan is subject to the requirements of the Act. 

The message to be placed in the 271 transaction is:

"Services provided to this patient are subject to the Balance Billing Protection Act. Please see RCW 48.49.020 for details."

The placement of the message within the 271 transaction is as follows:

a. In an existing:

  • Loop 2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION,  OR
  • Loop 2110D - DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

b. For the EB segment where EB01=1,2,3,4,5,6,7,8 (active or inactive coverage)

    Place the message in the MSG segment

      Example:

         EB*1*IND*30*PR*THIS IS THE PLAN NAME~

         MSG* Services provided to this patient are subject to the Balance Billing Protection Act. Please see RCW 48.49.020 for details~

Note to providers - there is a limit of 10 messages per each 2110 Loop. If this messages causes the health plan to have more than 10 messages, a separate Loop for the message may be created.

2. Usage of X12 835 Transaction (5010 Version) - "Best Practice Recommendation"

The Balance Billing Protection Act (BBPA) requires that:

  • Consumer cost-sharing is limited to in-network cost-sharing, based upon the health insurer’s median in-network contracted rate. 
  • Allowed amount paid to an OON provider for health care services described in section 6 of the act is a commercially reasonable amount, based on payments for the same or similar services in a similar geographic area. 
  • Health insurers must make information available to a provider regarding whether the enrollee’s health plan is subject to the balance billing prohibition.
  1. For claims subject to the BBPA, the following is the Best Practice Recommendation for 835 reporting by the primary payer: 
    1. The best practice is to use an OA 209 followed by N830 to report the charge amount that is to written off. 
    2. For health plans that cannot report using an OA 209, an acceptable practice is to use a CO 45 followed by N830 to report the charge amount that is to be written off.  As such, in the below examples, CO 45 can replace OA 29.
CO

Contractual Obligation

Start: 05/20/2018

OA

Other Adjustment

Start: 05/20/2018

 45

Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability)
Start: 01/01/1995 | Last Modified: 07/01/2017

209

Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use only with Group code OA)
Start: 07/09/2007 | Last Modified: 07/01/2013

N830

ALERT: The charge(s) for this service was processed in accordance with Federal/State Balance/Surprise Billing regulations. As such, any amount identified with "OA", "CO", or "PI" cannot be collected from the member and may be considered provider liability or be billable to a subsequent payer. Any amount the provider collected over the identified "PR" amount must be refunded to the patient within applicable Federal/State timeframes. Payment amounts are eligible for dispute following any Federal/State documented appeal/grievance/arbitration process.

Below are possible scenarios and coding examples of how 835 reporting might look for BBPA-type claims before and after the legislation.  (These scenarios and examples are not an exhaustive list.  In these examples, the best practice is used rather than the acceptable practice. Also, for the sake of simplicity, these scenarios do not include possible reporting variations of patient deductible amounts.

Out-of-Network Provider at In-Network Facility

Scenario: Patient has an out-of-network provider rendering a service at an in-network hospital. The provider’s charge is $150 for the service. The carrier’s allowed amount for this service is $100.  

Pre - Balance Bill Protection Act 

Provider Paid $40
Patient owes $110

Claim Level

REF*CE - out of network

Line Level

SVC*HC:A*150*40~
CAS*PR*2*110

Post - Balance Bill Protection Act 

Provider paid $80
Patient owes $20
Provider “adjustment” $50

Claim Level 

REF*CE – ??? 

Line Level

SVC*HC:A*150*80~
CAS*PR*2*20
CAS*OA*209*50
LQ*N830

Emergency Services at an Out-of-Network Emergency Room

Scenario: Patient seeks emergency services at an out-of-network hospital. The hospitals charge is $1,500 for the service. The carrier’s allowed amount for this service is $1000.  

Pre - Balance Bill Protection Act 

Provider Paid $400
Patient owes $1100

Claim Level (if paid at claim level)

CLP*777777*1*1500*400* 1100 *15*123456789*23*1~
CAS*PR*2*1100~
NM1*QC*1*LAST*FIRST*MIDDLE***HN*456456456~
REF*CE – out of network

OR

Line Level  (if paid at line level)

SVC*HC:A*1500*400~
CAS*PR*2*1100

Post - Balance Bill Protection Act 

Provider paid $800
Patient owes $200
Provider “adjustment” $500

Claim Level  (if paid at claim level)

CLP*777777*1*1500*800*200*15*123456789*23*1~
CAS*PR*2*200~
CAS*OA*209*500~
NM1*QC*1*LAST*FIRST*MIDDLE***HN*456456456~
MOA***N830
REF*CE – ???

OR

Line Level (if paid at line level)

SVC*HC:A*1500*800~
CAS*PR*2*200
CAS*OA*209*500
LQ*N830

Reprocessing of Claim when payment amount is increased

In those situations when a BBPA claim is reprocessed to reflect an increased payment to an out-of-network provider and the consumer cost-sharing amount from the original adjudication of the claim will remain the same

Original Claim Example

CLP*AABBCC*1*120*80*20*12*1234500~
CAS*PR*2*20~
CAS*OA*209*20~

Following an agreement between the health plan and the provider to change the payment amount (e.g. from $80 to $90), the health plan will send the provider an 835 with the following information pertaining to the take back:

  1. A CLP reversing the previously processed claim. (take-back)

Reversal Claim Example

CLP*AABBCC*22*-120*-80**12*1234500~
CAS*PR*2*-20~
CAS*OA*209*-20~ 

  1. A CLP with the corrected claim information

New Claim Example

CLP*AABBCC*1*120*90*20*12*1234501~
CAS*PR*2*20~
CAS*OA*209*10~ 

  1. No PLB segment is required when using this method

Notes:

  • RARC N830 will be used in a MIA/MOA or service line LQ segment, as appropriate for the claim.  The service line example would be identical but the CLP segment would be replaced with a Service Line.   
  • The reversal should show prior to the correction.
  • When payment is taken-back/reversed, the adjustment Group and Reason Codes reported on the reversal should be the same as the adjustment Group and Reason Codes reported on the original adjudication. (Also stated on pages 9 & 13.)
  1. For claims subject to the BBPA, the following is the Best Practice Recommendation(s) for 835 reporting by a secondary, tertiary, etc. payer 

Developing a BPR for 835 reporting by subsequent payers was considered.  However, given the many possible scenarios and the unknown likelihood and frequency of those scenarios, the workgroup is waiting until specific BBPA-claim questions related to 835 reporting by secondary/tertiary payers are brought to the workgroup for consideration.  Specific cases can be submitted to bill@onehealthport.com for consideration by the workgroup.