Wash. Admin. Code § 284-43B-040

Current through Register Vol. 25-01, January 1, 2025

Section 284-43B-040 - Determining whether an enrollee's health plan is subject to the requirements of the act

(1) To implement RCW 48.49.170, carriers must make information regarding whether an enrol-lee's health plan is subject to the requirements of chapter 48.49 RCW or section 2799A-1 et seq. of the Public Health Service Act (42 U.S.C. Sec. 300gg-111 et seq.) and federal regulations implementing those provisions of P.L. 116-260 available to providers, facilities, and ground ambulance services organizations by:

(a) Using the most current version of the Health Insurance Portability and Accountability Act (HIPAA) mandated X12 Health Care Eligibility Benefit Response (271) transaction information through use of the most appropriate standard message that is placed in a standard location within the 271 transaction;

(b) Using the appropriate version of the Health Insurance Portability and Accountability Act (HIPAA) mandated X12 Health Care Claim Payment and Remittance Advice (835) transaction through compliant use of the applicable X12 industry standard Remark Code to indicate whether a claim was processed in accordance with this state's balance billing rules or the federal No Surprises Act.

(2) The commissioner:

(a) After consultation with carriers, providers and facilities through a new or an existing workgroup or committee, must post the language of the most appropriate standard message and the location within the 271 transaction in which the message is to be placed on its website;

(b) Must post on its website instructions on compliant use of the appropriate X12 industry standard Remark code or codes as provided in subsection (1)(b) of this section; and

(c) Must post on its website the information reported by carriers under WAC 284-43B-035(1).

(3) A link to the information referenced in subsection (2) of this section also must be posted on the website of the office of the insurance commissioner.

Wash. Admin. Code § 284-43B-040

Adopted by WSR 19-23-085, Filed 11/19/2019, effective 12/20/2019

Amended by WSR 20-22-076, Filed 11/2/2020, effective 12/3/2020

Amended by WSR 23-01-110, Filed 12/19/2022, effective 1/19/2023

Amended by WSR 24-24-065, Filed 11/27/2024, effective 12/28/2024