For services described in RCW 48.49.020(1) (other than air ambulance services) provided prior to July 1, 2023, or a later date determined by the commissioner, and for services provided by a nonparticipating emergency behavioral health services provider if the federal government does not authorize use of the federal independent dispute resolution system for these disputes, the allowed amount paid to a nonparticipating provider or facility for emergency services and nonemergency health care services performed by nonparticipating providers at certain participating facilities, shall be a commercially reasonable amount, based on payments for the same or similar services provided in the same or a similar geographic area.

1. (1) Within 30 calendar days of receipt of a claim from a nonparticipating provider or facility, the carrier shall offer to pay the provider or facility a commercially reasonable amount. Payment of an adjudicated claim shall be considered an offer to pay. The amount actually paid to a nonparticipating provider by a carrier may be reduced by the applicable consumer cost-sharing determined under WAC 284-43B-020 (1)(a). The date of receipt by the provider or facility of the carrier's offer to pay is five calendar days after a transmittal of the offer is mailed to the provider or facility, or the date of transmittal of an electronic notice of payment. The claim submitted by the nonparticipating provider or facility to the carrier must include the following information:

   1. (a) Patient name;
   2. (b) Patient date of birth;
   3. (c) Provider name;
   4. (d) Provider location;
   5. (e) Place of service, including the name and address of the facility in which, or on whose behalf, the service that is the subject of the claim was provided;
   6. (f) Provider federal tax identification number;
   7. (g) Federal Center for Medicare and Medicaid Services individual national provider identifier number, and organizational national provider identifier number, if the provider works for an organization or is in a group practice that has an organization number;
   8. (h) Date of service;
   9. (i) Procedure code; and
   10. (j) Diagnosis code.
2. (2) If the nonparticipating provider or facility wants to dispute the carrier's offer to pay, the provider or facility must notify the carrier no later than 30 calendar days after receipt of the offer to pay or payment notification from the carrier. A carrier may not require a provider or facility to reject or return payment of the adjudicated claim as a condition of putting the payment into dispute.
3. (3) If the nonparticipating provider or facility disputes the carrier's offer to pay, the carrier and provider or facility have 30 calendar days after the provider or facility receives the offer to pay to negotiate in good faith.
4. (4) If the carrier and the nonparticipating provider or facility do not agree to a commercially reasonable payment amount within the 30-calendar day period under subsection (3) of this section, and the carrier, nonparticipating provider or nonparticipating facility chooses to pursue further action to resolve the dispute, the dispute shall be resolved through arbitration, as provided in RCW 48.49.040.

[Statutory Authority: RCW 48.43.820, 48.49.180, 48.49.110, and 48.02.060. WSR 23-01-110 (Matter R 2022-02), § 284-43B-030, filed 12/19/22, effective 1/19/23. Statutory Authority: RCW 48.49.060 and 48.49.110. WSR 20-22-076, § 284-43B-030, filed 11/2/20, effective 12/3/20. Statutory Authority: RCW 48.02.060, 48.49.060, and 48.49.110. WSR 19-23-085, § 284-43B-030, filed 11/19/19, effective 12/20/19.]