VirginiaSB1642026 Regular SessionSenateWALLET

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

Sponsored By: Jeremy S. McPike (Democratic)

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

9 provisions identified: 6 benefits, 0 costs, 3 mixed.

Insurers must pay approved and necessary care

Carriers must pay for services they previously authorized or confirmed as medically necessary and covered, except for fraud, missing documentation, another payer’s responsibility, duplicate payment, or discovered ineligibility. They must also pay for additional or different procedures done during surgery when they were not investigative, were medically necessary, were coded correctly, and followed post‑service rules. Providers can confirm coverage, medical necessity, and processing rules in advance by phone or electronic means at no cost. Beginning July 1, 2025, carriers give providers an electronic way to check if a patient is covered.

Stronger protections against claim downcoding

Carriers cannot downcode a claim unless a person or a correct system reviews all documented patient data. They must send the reason code with any downcoding. You have at least 180 days to dispute, a real person must review dispute decisions, and you may batch similar claims. If a carrier bundles or downcodes as a policy, it must say so in your contract and share the written rules within 10 business days when you ask.

New remedies and safeguards for providers

Providers gain a private right to sue carriers for actual losses, with up to triple damages for gross, willful violations, plus attorney fees and costs. Carriers, networks, and panels cannot punish a provider for using rights under this law or a contract. Before filing a Commission complaint about unpaid claims, a provider must try to resolve it with the carrier and wait 30 days, unless the carrier is unresponsive, and attest to that in the complaint. A carrier is not in violation if the submitter caused the problem or an outside event made compliance impossible.

Faster, clearer prior authorization decisions

Beginning January 1, 2027, insurers must answer prior authorization requests in 72 hours for urgent cases and seven days for standard cases. If they deny or need more information, they must say why and what is needed, and decide again within the same timelines after you submit it. Once care is approved and scheduled or given, the insurer cannot take back or narrow the approval except for fraud, provider-requested changes, federal or manufacturer actions, or if the member leaves the plan. Insurers must post one public list of services and billing codes that need prior authorization. If they did not post the rule for your date of service, they cannot deny a claim for missing prior authorization.

Faster, fairer claim payments to providers

Carriers must pay clean claims within 40 days unless they have a documented reason, like fraud or eligibility problems. Within 30 days of getting a claim, they must tell the submitter what is missing and ask for the needed information; starting January 1, 2026, these notices are electronic. Carriers must keep the date they received each claim and let the submitter see it, and they must pay any interest when they pay the claim or within 60 days after. If a denial is overturned, the claim becomes a clean claim that day and must follow clean‑claim timelines. Carriers cannot claw back payments unless they give written reasons and it is fraud, a duplicate/not delivered, or within 12 months; they must give 30 days’ notice, and by January 1, 2026, these notices are electronic.

Stronger provider contract and payment terms

Provider contracts must include the fee schedule or a clear payment formula and the key policies. Carriers must send contract changes at least 60 days before they take effect, and providers then have 30 days to choose to end the contract at the earliest allowed date. Carriers send contracts, amendments, and notices to providers electronically by July 1, 2025; providers must send them electronically by January 1, 2026 using the agreed method in the contract. If a payment method charges a fee, the carrier must disclose it and offer a no‑fee option, and must pay that way if you enroll. If copyright blocks sharing a full policy, the carrier must give a clear written explanation of how the rule applies.

Electronic prior authorization and public reports

Insurers must run a prior authorization computer interface (API) by January 1, 2027, following federal rules. Within one year after that, providers must let their electronic health records connect to the API; a waiver is available for undue hardship. By March 31 each year, insurers post plan‑level prior authorization data, and in emergencies they may drop prior authorization without 30 days’ notice. Certain HMOs are exempt starting January 1, 2027 if they use an employed multispecialty physician group. A state work group tracks this and reports yearly by November 1 (final by November 1, 2028) with a November 1, 2025 recommendation, and the insurance commission can set detailed rules.

No denying care for crash litigants

Provider contracts must bar providers from denying care just because a patient is a litigant or possible litigant from a car crash. A provider may still refuse to treat someone who threatened or filed a claim or complaint against that provider or the provider’s employer.

State oversight of carriers and providers

The state insurance regulator can decide if a carrier violated required contract terms or fair‑business standards, and it may write rules to carry out the law. It does not resolve individual payment disputes between one provider and one carrier. If the regulator sees a provider’s pattern of potential violations that is not corrected, it may refer the case to the Board of Medicine or the Health Commissioner for action. These duties apply even when carriers or providers use vendors or subcontractors.

Sponsors & Cosponsors

Sponsor

  • Jeremy S. McPike

    Democratic • Senate

Cosponsors

There are no cosponsors for this bill.

Roll Call Votes

All Roll Calls

Yes: 260 • No: 1

Senate vote 3/6/2026

House substitute with amendments agreed to by Senate

Yes: 40 • No: 0

House vote 3/4/2026

Passed House with substitute with amendments

Yes: 97 • No: 1

House vote 2/26/2026

Reported from Labor and Commerce with substitute

Yes: 21 • No: 0

House vote 2/24/2026

Subcommittee recommends reporting with substitute

Yes: 9 • No: 0 • Other: 1

Senate vote 1/30/2026

Read third time and passed Senate Block Vote

Yes: 38 • No: 0

Senate vote 1/29/2026

Engrossed by Senate Block Vote (Voice Vote)

Yes: 0 • No: 0

Senate vote 1/29/2026

Commerce and Labor Substitute agreed to

Yes: 0 • No: 0

Senate vote 1/28/2026

Constitutional reading dispensed Block Vote (on 1st reading)

Yes: 40 • No: 0

Senate vote 1/28/2026

Passed by for the day Block Vote (Voice Vote)

Yes: 0 • No: 0

Senate vote 1/26/2026

Reported from Commerce and Labor with substitute

Yes: 15 • No: 0

Actions Timeline

  1. Acts of Assembly Chapter text (CHAP0881)

    4/13/2026Governor
  2. Approved by Governor-Chapter 881 (effective 7/1/2026)

    4/13/2026Governor
  3. Fiscal Impact Statement from State Corporation Commission (SB164)

    3/24/2026Senate
  4. Governor's Action Deadline 11:59 p.m., April 13, 2026

    3/14/2026Governor
  5. Enrolled Bill communicated to Governor on March 14, 2026

    3/14/2026Senate
  6. Bill text as passed Senate and House (SB164ER)

    3/12/2026Senate
  7. Enrolled

    3/12/2026Senate
  8. Signed by President

    3/12/2026Senate
  9. Signed by Speaker

    3/12/2026House
  10. House substitute with amendments agreed to by Senate (40-Y 0-N 0-A)

    3/6/2026Senate
  11. Passed House with substitute with amendments (97-Y 1-N 0-A)

    3/4/2026House
  12. Engrossed by House - committee substitute as amended

    3/4/2026House
  13. Delegate Shin Floor amendments agreed to

    3/4/2026House
  14. Labor and Commerce Substituteagreed to by House

    3/4/2026House
  15. Reconsideration of

    3/4/2026House
  16. Floor Offered

    3/4/2026House
  17. Passed by temporarily

    3/4/2026House
  18. committee substitute rejected

    3/4/2026House
  19. Read third time

    3/4/2026House
  20. Fiscal Impact Statement from State Corporation Commission (SB164)

    3/3/2026Senate
  21. Passed by for the day

    3/3/2026House
  22. Moved from Uncontested Calendar to Regular Calendar

    3/3/2026House
  23. Read second time

    3/2/2026House
  24. Committee substitute printed 26108190D-H1

    2/27/2026House
  25. Reported from Labor and Commerce with substitute (21-Y 0-N)

    2/26/2026House

Bill Text

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