Reference Based Pricing

A Starting Point for Comparing Costs

Reference Based Pricing (RBP) is a method of determining the cost of a medical service. This begins with a reference point price – such as any free-market price (KPPFree™) or a commonly known price, such as Medicare. Medicare is used as a commonly understood language and as a starting point for a mutual negotiation, increasing overall transparency and enhancing patient choice.

How Does RBP Work?

A plan that includes Reference Based Pricing has standard benefits, such as copays, deductibles and coinsurance. When you visit your doctor, they will file a claim using the EDI# on your medical ID card, just like they would normally.

When the claim is processed, reimbursement is based on the RBP amount determined by your plan benefits and the type of provider, plus an additional amount.

Typically, your doctor will agree this is a fair and reasonable reimbursement. If they do not, please reach out to us. Balance billing is not the end of the conversation. There are resources available to assist you.

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Examples of Reference Prices

  • Free-Market Price, such as KPPFree
  • Online retailers
  • A percentage above the amount paid to the provider by Medicare


Many benefit plans utilize RBP for out-of-network benefits, or as a replacement for a PPO network. If you have questions about your RBP benefits, please contact us.

How do you know if your plan is contracted with a network?

To determine whether your plan has contracted with a PPO network, review the Medical Plan section of your ID card, log in to our Secure Benefit Portal, or contact us.

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