WASHINGTON

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The Washington SBL became effective January 1, 2020. RCW 48.49.030(2). The relevant provisions of the Washington law include:

• Reimbursement is tied to UCR where several factors can be considered to determine what is “commercially reasonable.”
• Arbitration is available when nothing is resolved after the 30-day negotiation period.
• Parties can consult the APCD.
• No timeline stated for instituting arbitration after the 30-day negotiation period runs.
• Notice requirements exist whereby the carrier must inform the provider the claim is subject to the NSA.

With respect to bifurcation, according to CMS,

Washington does not have an applicable All-Payer Model Agreement that would determine the out-of-network rate. Based on the survey response, CMS research, and CMS communications with Washington Office of the Insurance Commissioner and Department of Health staff, CMS understands that RCW 48.49.030(2) is a specified state law that will apply for purposes of determining the out-of-network rate with respect to emergency (screening and stabilization) services provided at a hospital; and non-emergency surgery, radiology, anesthesiology, pathology, hospitalist, or laboratory services provided by an in-network hospital or ambulatory surgical facility. The federal independent dispute resolution process under sections 2799A-1(c) and 2799A-2(b) of the PHS Act and 45 CFR 149.510 and 149.520 will apply for purposes of determining the out-of-network rate with respect to any items and services furnished to individuals in an insured group health plan, or group or individual health insurance coverage in Washington and nonparticipating providers, nonparticipating emergency facilities, and nonparticipating providers of air ambulance services to which RCW 48.49.030(2) does not apply. Washington Office of the Insurance Commissioner will enforce the outcome of the federal independent dispute resolution process for such cases in Washington.

Letter from CMS to Governor of Washington, dated December 21, 2021.