VirginiaHB4842026 Regular SessionHouseWALLET

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

Sponsored By: Jen Kiggans - to resign 12/31 (Republican)

Became Law

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

6 provisions identified: 4 benefits, 0 costs, 2 mixed.

Quicker, clearer prior authorization decisions

Beginning January 1, 2027, insurers must decide urgent prior authorization requests within 72 hours (including weekends) and standard requests within seven calendar days. If more information is needed, the insurer must say exactly what, and must decide within the same time limits after you send it. If denied, the insurer must give the reasons within those timeframes. Insurers must post a public list of services and codes that need prior authorization and give providers at least 30 days’ notice before changes; forms must be updated and effective dates shown. If rules for the date of service were not posted, the claim cannot be denied for lack of authorization. Once approved, an authorization cannot be revoked for scheduled or delivered care except for provider‑requested changes, fraud or misrepresentation, or federal/manufacturer safety actions; this does not apply if the member is no longer enrolled. During a pandemic, natural disaster, or other emergency, insurers may remove prior authorization without the 30‑day notice, and some HMOs with multispecialty physician groups are exempt from these posting and notice rules.

Faster, fairer claim payments for providers

Insurers must pay clean claims within 40 days. They must keep the claim receipt date and let you rely on it. If a denial is overturned, the claim becomes a clean claim that day. Interest owed on late claims must be paid when the claim is paid or within 60 days after. Contracts must include fee schedules and key policies, and any fee-based payment option must come with a no‑fee alternative you can choose. Carriers must give 60 days’ notice before contract changes, and you have 30 days to opt to end the contract.

Limits on recoupments and downcoding

Insurers must pay claims they approved or said were medically necessary, unless the records do not support the claim, another payer must pay, the claim was fraudulent, a duplicate, or the patient was not eligible and that was reasonably knowable. Extra medically necessary procedures found during surgery must be paid if they are not investigative, are coded correctly, and are submitted under plan rules. Takebacks of paid claims are allowed only for fraud, duplicate or incorrect payments, or within 12 months, and insurers must name the claim and reason and give 30 days’ written notice; starting January 1, 2026, these notices and responses are electronic. Downcoding must be done by a qualified person or a correct coding system using all relevant patient data, and carriers must tell you when they downcode and list the adjustment codes. You have at least 180 days to dispute downcoding, and a real person must decide the dispute. Carriers must disclose bundling/downcoding practices and provide related policies within 10 business days on request.

Electronic prior authorization and plan reporting

Insurers must set up an electronic prior authorization API by January 1, 2027, under federal standards; CMS can change that date or enforcement. Within one year after that, providers’ EHRs must be able to use the API, with hardship waivers available. Each year by March 31, plans must post prior authorization performance data for the prior year. The State Corporation Commission can issue rules to carry out these requirements starting in 2027. The Bureau of Insurance leads a stakeholder work group that reports every November 1 and submits a final report by November 1, 2028; the November 1, 2025 report must assess readiness, include real‑time prescription drug cost‑benefit information, and recommend a statewide implementation date.

Provider enforcement tools and fairness rules

Providers who lose money from a carrier’s violation can sue for actual damages, and up to three times the loss for willful, grossly negligent conduct, plus attorney fees and costs; each bad claim is a separate violation. Carriers cannot fire, refuse to renew, or punish a provider for using rights under this law. Before filing a payment complaint with the Commission, providers must try to resolve it with the carrier and, if the carrier responds, wait 30 days. The Commission enforces fair‑business standards and can make rules, but it does not decide individual disputes. Duties apply even when carriers or providers use subcontractors or vendors. A carrier is not at fault if the submitter caused the problem or events beyond the carrier’s control made compliance impossible. Provider contracts must bar discrimination against enrollees just because they are or may be litigants; if a provider shows a pattern of violating this, the Commission may refer the case to the Board of Medicine or the Health Commissioner.

Shift to all-electronic provider communications

By July 1, 2025, carriers must deliver provider contracts, amendments, and notices electronically (not by fax) using the agreed method in the contract. Starting January 1, 2026, providers must send their contracts, changes, and notices to carriers by the agreed electronic method. By July 1, 2025, carriers must offer providers an electronic way to check a patient’s coverage. By January 1, 2026, carriers must send claim defect notices and information requests electronically.

Sponsors & Cosponsors

Sponsor

  • Jen Kiggans - to resign 12/31

    Republican • Senate

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

Passed Senate with substitute Block Vote

Yes: 40 • No: 0

Senate vote 2/26/2026

Commerce and Labor Substitute agreed to

Yes: 0 • No: 0

Senate vote 2/25/2026

Passed by for the day Block Vote (Voice Vote)

Yes: 0 • No: 0

Senate vote 2/25/2026

Constitutional reading dispensed Block Vote (on 2nd reading)

Yes: 40 • 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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