VirginiaHB4842026 Regular SessionHouseWALLET

Health insurance; ethics and fairness in carrier business practices, downcoded claims.

Sponsored By: Irene Shin (Democratic)

Signed by Governor

Summary

Health insurance; ethics and fairness in carrier business practices; downcoded claims. Prohibits a carrier, intermediary, administrator, or representative of a carrier from downcoding a claim unless the decision to downcode is determined by a person or electronic system that reflects correct coding standards and considers all relevant patient data from the billing provider in making the determination. The bill requires a carrier, intermediary, administrator, or representative that downcodes a claim to provide certain notice to the provider. The bill requires that all downcoding dispute decisions are reviewed and adjudicated by a natural person.

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Bill Overview

Analyzed Economic Effects

14 provisions identified: 10 benefits, 1 costs, 3 mixed.

Accident lawsuits cannot alone block care

Carrier-provider contracts must bar discrimination solely because an enrollee is suing, or may sue, over a motor vehicle accident. This does not require treatment when the enrollee threatened or brought a professional-liability claim or regulatory complaint against the provider or specified related people. The Commission may refer patterns of possible violations without corrective action to the Board of Medicine or Health Commissioner. It may first let the provider correct or explain the conduct. Those officials may impose fines, recover costs, or take other authorized action, and must report results to the Commission.

Patients get deadlines for care approvals

Beginning January 1, 2027, carriers must respond to expedited care-approval requests within 72 hours, including weekends. Standard requests have a seven-calendar-day deadline. Responses must approve, deny, or identify missing information; completed additions trigger the same deadline for a final decision. Denial reasons must reach the provider or designated contact electronically or by phone within those deadlines. Carriers generally cannot change approvals after care is scheduled or provided as approved. Exceptions cover provider-requested changes, fraud or misrepresentation, specified federal or manufacturer actions, and loss of plan enrollment.

Patients get publicly posted approval rules

Beginning January 1, 2027, carriers must publicly post care-approval services, codes, procedures, forms, and effective dates in one electronic location. Providers must get at least 30 calendar days’ notice of changes, and postings must be updated when changes start. Advance notice is not required when approval requirements are removed during a pandemic, disaster, or other emergency. Older requirements may list January 1, 2027, as their effective date. Carriers cannot deny claims for missing approval when the requirements on the service date were not properly posted.

Fair insurance rules cover more carriers

Virginia’s fair-business rules cover more licensed entities that offer managed-care plans or arrange health services regulated as insurance. Carriers and providers remain responsible for covered duties when vendors or subcontractors do the work.

Insurers face limits on reclaiming payments

Carriers must identify and explain a paid claim in writing before denying it afterward or seeking repayment. Recovery requires fraud, duplicate payment, services not delivered, or payment made no more than 12 months earlier. A written agreement can allow withholding or offset after 12 months, with at least 30 days’ advance notice. Required communications and provider responses must be electronic by January 1, 2026, using a contract-agreed method and location.

Providers can avoid claim payment fees

Carriers must disclose payment methods that charge providers transaction, processing, or similar fees in provider contracts. This includes methods used by payment agents. Carriers must offer a fee-free option. They must use it when the provider chooses it and supplies the required enrollment information.

Providers can challenge claim coding reductions

Carriers may lower a claim’s service code only through a person or system using correct coding standards and relevant patient data. They must notify providers and identify the adjustment and payment-explanation codes. Providers get at least 180 days to dispute coding reductions, human review of every dispute decision, and reasonable review and appeal deadlines. They may group disputes for one patient, following their contract and federal health privacy rules. These coding protections exclude limited-scope benefits, including stand-alone dental plans. Carriers must also offer a written process for claim-payment disputes; an overturned denial becomes a clean claim on the decision date.

Providers get clearer claim payment deadlines

Carriers must pay provider-contract claims within 40 days of receipt when payment is reasonably clear. Supported disputes about claims, eligibility, another payer, or fraud can delay payment. Carriers must keep receipt-date records that claim submitters can inspect. A clean claim includes provider and patient details, service codes, diagnoses, date and place, required authorization proof, and contract-required records. Carriers must report defects and request missing information within 30 days; payment deadlines apply after that information arrives. Missing the notice deadline makes a claim clean, and generally bars refusing covered-service payment unless the submitter materially caused the notice failure. Claim-defect notices and information must be electronic by January 1, 2026. Interest owed must be paid without a demand, with claim payment or within 60 days afterward, unless due sooner.

Providers get clearer insurance contract terms

Carriers must provide applicable fee schedules, payment methods, and material contract documents before providers sign. They must offer ways to check coverage, medical need, authorization, reimbursement, coding, and claim-processing rules. Contracts must disclose routine claim combining or coding reductions; requested policies are due within 10 business days. When copyright blocks sharing a policy, carriers must clearly explain how it applies. Applicable contract or policy changes require 60 calendar days’ advance notice. Providers have 30 calendar days after receiving changes to give notice that they will leave at the earliest contract-allowed date.

Providers get payment protections for approved care

Carriers must pay for services they approved or confirmed in advance as medically needed and covered. Exceptions include unsupported claims, another responsible payer, prior payment, fraud, major wrong information, and certain ineligible enrollees. Fraud found after care can also justify denial. When new clinical evidence changes an approved invasive procedure or surgery, carriers must pay for qualifying less or more extensive care. Changed care must be medically needed, covered, not investigative, correctly coded, and submitted under the carrier’s claim rules.

Some health plans lack approval protections

The law’s prior-approval section does not cover certain health maintenance organizations. The plan must contract with a multispecialty physician group whose doctors are both employees and shareholders. The group may also contract with community providers. The plan must provide and arrange physician services through group members or those contracted providers. Enrollees in these qualifying plans do not receive that section’s protections.

Online care approvals require provider upgrades

Carriers must maintain an electronic connection for providers’ approval requests for medical items and services, following federal standards. The deadline is January 1, 2027, unless the Centers for Medicare and Medicaid Services sets a later date. Federal enforcement delays or suspensions can also move that deadline. Within one year of the required carrier start date, participating providers must make their health-record systems able to connect. Providers may request an undue-hardship waiver for a period set by the appropriate Virginia health regulatory agency.

Providers gain remedies, face complaint steps

Providers harmed by carrier violations or breaches of required contract terms may sue for actual losses. A finding of gross negligence and willful conduct allows up to three times actual losses; legal fees and court costs may also be awarded. Each affected claim counts separately, and carriers, networks, panels, and intermediaries cannot punish providers for asserting legal or contract rights. Before a late-payment complaint, providers must request a conference from the contract contact, supply supporting records, and document reasonable efforts. They generally must wait 30 calendar days, unless they judge the carrier unresponsive, and confirm compliance in the complaint. The Virginia State Corporation Commission oversees required contract terms and payment and defect-notice standards, but cannot decide individual disputes under this section.

Providers get coverage checks, electronic paperwork

Beginning July 1, 2025, carriers under Virginia State Corporation Commission oversight must offer providers electronic coverage checks. Carriers must also send provider contracts, amendments, and notices electronically by July 1, 2025. Providers must submit those materials electronically by January 1, 2026. Fax does not count. Both sides must put their agreed delivery method and location in the contract; coverage checks do not change eligibility.

Sponsors & Cosponsors

Sponsor

  • Irene Shin

    Democratic • House

Cosponsors

There are no cosponsors for this bill.

Roll Call Votes

All Roll Calls

Yes: 457 • No: 3

House vote • 4/22/2026

House concurred in Governor's recommendation

Yes: 99 • No: 1

Senate vote • 4/22/2026

Senate concurred in Governor's recommendation

Yes: 39 • No: 0

House vote • 3/2/2026

Senate substitute agreed to by House

Yes: 98 • No: 0

Senate vote • 2/26/2026

Commerce and Labor Substitute agreed to

Yes: 0 • No: 0

Senate vote • 2/26/2026

Passed Senate with substitute Block Vote

Yes: 40 • No: 0

Senate vote • 2/25/2026

Constitutional reading dispensed Block Vote (on 2nd reading)

Yes: 40 • No: 0

Senate vote • 2/25/2026

Passed by for the day Block Vote (Voice Vote)

Yes: 0 • No: 0

Senate vote • 2/23/2026

Reported from Commerce and Labor with substitute

Yes: 14 • No: 0

House vote • 2/11/2026

Read third time and passed House

Yes: 97 • No: 1

House vote • 2/5/2026

Reported from Labor and Commerce with substitute

Yes: 21 • No: 1

House vote • 2/3/2026

Subcommittee recommends reporting with substitute

Yes: 9 • No: 0

Actions Timeline

  1. Senate concurred in Governor's recommendation (39-Y 0-N 0-A)

    4/22/2026Senate
  2. House concurred in Governor's recommendation (99-Y 1-N 0-A)

    4/22/2026House
  3. Acts of Assembly Chapter text (CHAP1055)

    4/22/2026Governor
  4. Approved by Governor-Chapter 1055 (effective 7/1/2026)

    4/22/2026Governor
  5. Signed by President

    4/22/2026Senate
  6. Signed by Speaker

    4/22/2026House
  7. Governor's recommendation adopted

    4/22/2026Governor
  8. Governor's recommendation received by House

    4/13/2026Governor
  9. Fiscal Impact Statement from State Corporation Commission (HB484)

    3/12/2026House
  10. Governor's Action Deadline 11:59 p.m., April 13, 2026

    3/10/2026Governor
  11. Enrolled Bill communicated to Governor on March 10, 2026

    3/10/2026House
  12. Bill text as passed House and Senate (HB484ER)

    3/5/2026House
  13. Enrolled

    3/5/2026House
  14. Signed by President

    3/5/2026Senate
  15. Signed by Speaker

    3/5/2026House
  16. Fiscal Impact Statement from State Corporation Commission (HB484)

    3/3/2026House
  17. Senate substitute agreed to by House (98-Y 0-N 0-A)

    3/2/2026House
  18. Passed Senate with substitute Block Vote (40-Y 0-N 0-A)

    2/26/2026Senate
  19. Commerce and Labor Substitute agreed to

    2/26/2026Senate
  20. Engrossed by Senate - committee substitute

    2/26/2026Senate
  21. Read third time

    2/26/2026Senate
  22. Passed by for the day Block Vote (Voice Vote)

    2/25/2026Senate
  23. Constitutional reading dispensed Block Vote (on 2nd reading) (40-Y 0-N 0-A)

    2/25/2026Senate
  24. Rules suspended

    2/25/2026Senate
  25. Committee substitute printed 26108293D-S1

    2/24/2026Senate

Bill Text

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