Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-43B - Balance billing › Section 284-43B-010 - Definitions

Current through Register Vol. 24-14, July 15, 2024
(1) The definitions
			 in RCW
			  48.43.005 apply throughout this chapter
			 unless the context clearly requires otherwise, or the term is defined otherwise
			 in subsection (2) of this section.
(2) The following definitions shall apply
			 throughout this chapter:
(a) "Air ambulance
			 service" has the same meaning as defined in
			 RCW
			  48.43.005.
(b) "Allowed amount" means the maximum
			 portion of a billed charge a health carrier will pay, including any applicable
			 enrollee cost-sharing responsibility, for a covered health care service or item
			 rendered by a participating provider or facility or by a nonparticipating
			 provider or facility.
(c) "Balance
			 bill" means a bill sent to an enrollee by a nonparticipating provider,
			 facility, behavioral health emergency services provider or air ambulance
			 service provider for health care services provided to the enrollee after the
			 provider or facility's billed amount is not fully reimbursed by the carrier,
			 exclusive of cost-sharing allowed under WAC
			 284-43B-020.
(d) "Behavioral health emergency services
			 provider" has the same meaning as defined in
			 RCW
			  48.43.005.
(e) "De-identified" means, for the purposes
			 of this rule, the removal of all information that can be used to identify the
			 patient from whose medical record the health information was derived.
(f) "Emergency medical condition" has the
			 same meaning as defined in
			 RCW
			  48.43.005.
(g) "Emergency services" has the same meaning
			 as defined in
			 RCW
			  48.43.005.
(h) "Facility" or "health care facility"
			 means:
(i) With respect to the provision of
			 emergency services, a hospital or freestanding emergency department licensed
			 under chapter 70.41 RCW (including an "emergency department of a hospital" or
			 "independent freestanding emergency department" described in section 2799A-1(a)
			 of the Public Health Service Act (42 U.S.C. Sec. 300gg-111(a)  and  45 C.F.R. Sec. 149.30)) or a behavioral health emergency services provider; and
(ii) With respect to provision of
			 nonemergency services, a hospital licensed under chapter 70.41 RCW, a hospital
			 outpatient department, a critical access hospital or an ambulatory surgical
			 facility licensed under chapter 70.230 RCW (including a "health care facility"
			 described in section 2799A-1(b) of the Public Health Service Act (42 U.S.C. Sec. 300gg-111(b)  and  45 C.F.R. Sec. 149.30)).
(i) "Hospital outpatient department" means an
			 entity or site that provides outpatient services and:
(i) Is a provider-based facility under  42 C.F.R. Sec. 413.65;
(ii) Charges a
			 hospital facility fee in billing associated with the receipt of outpatient
			 services from the entity or site; or
(iii) Bills the consumer or their health plan
			 under a hospital's national provider identifier or federal tax identification
			 number.
(j) "In-network"
			 or "participating" means a provider or facility that has contracted with a
			 carrier or a carrier's contractor or subcontractor to provide health care
			 services to enrollees and be reimbursed by the carrier at a contracted rate as
			 payment in full for the health care services, including applicable cost-sharing
			 obligations. A single case reimbursement agreement between a provider or
			 facility and a carrier used for the purpose described in WAC
			 284-170-200 constitutes a
			 contract exclusively for purposes of this definition under the Balance Billing
			 Protection Act and is limited to the services and parties to the
			 agreement.
(k) "Nonemergency health
			 care services performed by nonpar-ticipating providers at certain participating
			 facilities" has the same meaning as defined in
			 RCW
			  48.43.005.
(l) "Offer to pay," "carrier payment," or
			 "payment notification" means a claim that has been adjudicated and paid by a
			 carrier to a nonparticipating provider for emergency services or for
			 nonemergency health care services performed by nonparticipat-ing providers at
			 certain participating facilities.
(m) "Out-of-network" or "nonparticipating"
			 has the same meaning as defined in
			 RCW
			  48.43.005.
(n) "Provider" means a person regulated under
			 Title 18 RCW or chapter 70.127 RCW to practice health or health-related
			 services or otherwise practicing health care services in this state consistent
			 with state law, or an employee or agent of a person acting in the course and
			 scope of his or her employment, that provides emergency services, or
			 none-mergency health care services at certain participating
			 facilities.