All Roll Calls
Yes: 260 • No: 1
Sponsored By: Jeremy S. McPike (Democratic)
Became Law
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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9 provisions identified: 6 benefits, 0 costs, 3 mixed.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Jeremy S. McPike
Democratic • Senate
There are no cosponsors for this bill.
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
Acts of Assembly Chapter text (CHAP0881)
Approved by Governor-Chapter 881 (effective 7/1/2026)
Fiscal Impact Statement from State Corporation Commission (SB164)
Governor's Action Deadline 11:59 p.m., April 13, 2026
Enrolled Bill communicated to Governor on March 14, 2026
Bill text as passed Senate and House (SB164ER)
Enrolled
Signed by President
Signed by Speaker
House substitute with amendments agreed to by Senate (40-Y 0-N 0-A)
Passed House with substitute with amendments (97-Y 1-N 0-A)
Engrossed by House - committee substitute as amended
Delegate Shin Floor amendments agreed to
Labor and Commerce Substituteagreed to by House
Reconsideration of
Floor Offered
Passed by temporarily
committee substitute rejected
Read third time
Fiscal Impact Statement from State Corporation Commission (SB164)
Passed by for the day
Moved from Uncontested Calendar to Regular Calendar
Read second time
Committee substitute printed 26108190D-H1
Reported from Labor and Commerce with substitute (21-Y 0-N)
Chaptered
4/13/2026
Enrolled
3/12/2026
Amendment
3/4/2026
Substitute
2/27/2026
Substitute
2/25/2026
Substitute
2/24/2026
Substitute
1/27/2026
Substitute
1/26/2026
Introduced
1/7/2026
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