What is RBP?
Reference-based pricing (RBP) is a method of pricing claims without relying on negotiated network rates. Instead of using a contracted rate, the plan pays a configured percentage of what Medicare would reimburse for the same service.
RBP only applies when no other rate is available. Out-of-network claims are priced in this order: a direct contract or pre-negotiated rate first, then the network or repricer if the plan has one, then the plan's maximum allowable. The maximum allowable is defined in the plan's SPD.
Related: Direct Contracts, Claim Reimbursements, Payer ID and real-time status
Allowed Amount = Medicare rate x plan multiplierFor example, if Medicare reimburses $200 for a service and the plan's RBP multiplier is 175%, the allowed amount would be $350.
RBP multipliers commonly range from 150% to 225% of Medicare, although the actual percentage depends on the plan's configuration. Plans can also apply different multipliers based on claim type, meaning professional and institutional claims may be priced differently.
The Medicare benchmark depends on the type of claim:
Professional claims: Priced using the Medicare Physician Fee Schedule, with adjustments for place of service and geographic location
Institutional claims: Inpatient stays are generally priced using Medicare's DRG-based payment methodology, which groups services based on diagnoses and procedures. Other institutional services may use different Medicare payment methodologies
Services without a Medicare rate: If no applicable Medicare rate exists, the system uses a configured fallback, typically a percentage of billed charges. If no fallback is available, the claim may require manual review
A few additional things to note:
Packaged services: Certain services, such as supplies or ancillary services, may be bundled into another service's reimbursement. These lines price at $0 and carry a packaged remark rather than an individual rate
RBP pricing tool: On the adjudication page, the RBP pricing tool shows the claim's price at 100% of Medicare, the plan's configured multiplier, and 200% of Medicare. This is useful for validating the allowed amount
RBP calculator: The RBP calculator in the portal sidebar estimates the allowed amount for most services. See Comparing costs to RBP
Why the Excess Doesn't Count Toward the Out-of-Pocket Maximum
On an RBP claim, the provider's billed amount is often significantly higher than the plan's allowed amount. This is because the provider's charges are not determined by the Medicare-based reimbursement calculation.
For claim reconciliation, the billed amount is broken down as follows:
Billed = member cost share + plan paid + non-covered + discountThe amount above the RBP allowance is treated as non-covered, rather than member cost sharing. This distinction matters because only recognized member cost sharing, such as deductibles, copays, and coinsurance applied to covered services, counts toward the member's deductible and out-of-pocket maximum. Non-covered amounts do not accumulate toward either limit, even if the member ultimately pays the provider.
For example:
Provider bills $1,000.
The RBP allowed amount is $350.
The member owes $70 in coinsurance.
The plan pays $280.
The remaining $650 is outside the RBP allowance.
In this example, only the $70 in coinsurance counts toward the member's out-of-pocket maximum. The remaining $650 may be subject to balance billing, depending on whether any protections apply.
Important: Meeting the out-of-pocket maximum does not necessarily protect members from balance bills on RBP plans. Amounts billed above the plan's allowed amount are not treated as covered member cost sharing.
Related: Out of Pocket Costs
Which Claims Are Protected Under the No Surprises Act (NSA)?
The No Surprises Act (NSA) provides protections against certain types of out-of-network balance billing.
For NSA-protected services, normal out-of-network RBP treatment may not apply. Instead, the claim must follow the applicable NSA pricing and in-network cost-sharing rules. The Qualifying Payment Amount (QPA), generally based on median contracted rates, is used in calculating cost sharing in many cases, although it is not necessarily the final amount paid to the provider.
The main protected categories include:
Emergency services: Qualifying emergency services are protected under NSA regardless of whether the provider or facility is in-network. Professional claims with place of service 23 and institutional claims with emergency department revenue codes are common indicators that the claim may qualify. These claims require in-network cost sharing under NSA rules
Air and water ambulance services: Professional claims with place of service 42 (Air or Water Ambulance) are automatically flagged as NSA-eligible in Yuzu. However, federal NSA protections only apply to qualifying air ambulance services. Water and ground ambulance services are generally excluded, although state protections may apply. Since POS 42 includes both air and water, flagged claims may require additional review
Out-of-network services at an in-network facility: Certain services performed by out-of-network providers at an in-network facility may qualify for NSA protection. A common example is an out-of-network anesthesiologist or radiologist billing separately for services performed during an in-network hospital visit
For the third category, Yuzu may flag the claim as potentially NSA-eligible and check whether there is a corresponding facility claim for the same dates of service, including the facility's network status.
Because the system cannot independently confirm whether a valid notice-and-consent waiver was obtained, potentially eligible claims may require manual review instead of automatic repricing. Some services, including many ancillary services, cannot have NSA protections waived through notice and consent.
Claims that fall outside NSA protections may still be subject to balance billing under an RBP arrangement, unless other federal or state protections or provider agreements apply.
Related: No Surprises Act Disputes
When a Member Gets a Balance Bill
When a member initiates contact about a balance bill, the first step is to confirm how the claim was priced and whether NSA protections should apply.
Review the claim's adjudication
Check whether the claim was:
Priced using the plan's RBP multiplier
Priced using the applicable NSA methodology or QPA
Flagged for potential NSA protection or manual review
If a claim was priced using RBP without an NSA flag, that does not automatically mean NSA protections are inapplicable. The claim may need to be reviewed to confirm whether the protection was missed.
Determine whether NSA protections apply
Review whether the claim involves:
Qualifying emergency services
Covered air ambulance services
Qualifying out-of-network services at an in-network facility
If the claim should have received NSA protection, escalate it for review and potential reprocessing rather than advising the member to pay the balance bill.
If the claim was correctly priced using RBP
If the claim does not qualify for NSA protection and was correctly priced using the plan's RBP configuration, the member may have exposure to the amount billed above the allowed amount.
Any balance-billing assistance, provider negotiation, or dispute process should follow the applicable plan and vendor procedures.
To dispute a balance bill, route it through Patient-Provider Disputes or No Surprises Act Disputes.
For NSA-protected claims, disputes over the out-of-network payment amount may qualify for the federal Independent Dispute Resolution (IDR) process. This is generally a process between the provider and the plan, rather than a process initiated by the member.
Advise the member on next steps
Members should generally avoid paying a disputed balance bill until the claim's pricing and any applicable protections have been reviewed.
If the service is NSA-protected, the provider generally cannot bill the member for the difference between its charges and the applicable out-of-network payment amount, beyond the member's required in-network cost sharing.