(1) An in-state, out-of-network hospital that is reimbursed in accordance with WAC 182-40-0300(2) may not charge to or collect from the patient, for a service covered by the patient's health plan, or a person who is financially responsible for the patient, an amount in addition to the reimbursement paid by the contractor under WAC 182-40-0300(2) other than cost-sharing amounts authorized by the terms of the public employees' benefits board or school employees' benefits board health plan.

(2) The hospital is prohibited from obtaining a patient's waiver of their rights to protection under this section.

(3) Cost-sharing amounts applied under this section for services rendered by a hospital that are covered by a fully insured contractor under an alternate access delivery request (AADR) approved by the office of the insurance commissioner under WAC 284-170-210 must comply with the terms of the AADR.

(4) When the authority receives or identifies information indicating that an out-of-network hospital may have violated subsection (1) of this section, the following actions apply:

(a) The authority conducts a balance billing review and provides notice to the hospital and any impacted contractor of the balance billing review.

(i) The notice may require the hospital to provide records and additional information or documentation relevant and necessary for the authority to evaluate and validate that the hospital received only those funds to which it was entitled under this chapter.

(ii) The hospital has 30 calendar days upon receipt of the notice to:

(A) Provide the requested information or documentation; or

(B) Request additional time to complete the request.

(iii) The authority grants additional time on a case-by-case basis, but the request must be received before the expiration of the original 30 calendar days to avoid a fine.

(b) Once a balance billing review begins:

(i) The hospital must retain all original records and supportive materials sent to the authority until the authority sends the balance billing determination notice to the hospital and all issues are resolved; and

(ii) Unless instructed to do so by the authority, the hospital must not adjust or rebill a claim or encounter within the scope of the balance billing activity until the authority has concluded the balance billing determination review.

(c) After the balance billing review, the authority provides a balance billing determination notice to the hospital and impacted health contractor.

(i) If the authority finds that the hospital has not balance billed, the authority issues a notice that the review is closed.

(ii) If the authority finds that the hospital has balance billed:

(A) The authority notifies the hospital it must reimburse the enrollee, if it has collected excess funds, within 30 calendar days from receipt of the balance billing determination notice and provide to the authority proof of payment, if any is owed, to the enrollee; and

(B) The authority may assess a fine on the hospital for balance billing according to WAC 182-40-1400, whether or not the member actually paid the amount inappropriately billed.

(iii) If the hospital has not repaid the enrollee any amount owed within 30 calendar days of the hospital's receipt of the balance billing determination notice from the authority, the authority may assess an additional fine according to WAC 182-40-1400.