HIPAA Transaction Usage Requirements

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 - WAC 284-43B-040
  2. Use of the X12 835 to be in compliance with the OIC's Final Rule - WAC 284-43B-040

 

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) - "Final Rule"

The Balance Billing Protection Act (BBPA) requires that:

  • Health insurers must make information available to a provider regarding whether the enrollee’s health plan is subject to the balance billing prohibition.

Beginning April 1, 2021, for claims subject to the BBPA, appropriate and compliant use of the X12 Remittance Advice Remark Code (RARC) N830 is required in order to indicate that the claim was processed in accordance with the state's balance billing rules.

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. Start: 03/01/2020