# Virginia SB164: Health insurance; ethics and fairness in carrier business practices, downcoded claims. Virginia SB164, Health insurance; ethics and fairness in carrier business practices, downcoded claims., is a 2026 Regular Session Senate bill sponsored by Jeremy S. McPike (Democratic); status signed, last action 2026-04-13 (Acts of Assembly Chapter text (CHAP0881)); PRIA reads it as touching household money (as of 2026-10-12). - Canonical: https://policyrisk.com/state-bill/VA-SB164-2026 - As of: 2026-10-12 - Plain-text twin of the page above; the HTML and this file carry the same facts. ## Facts - Bill: Virginia SB164 - State: Virginia - Session: 2026 Regular Session - Title: Health insurance; ethics and fairness in carrier business practices, downcoded claims. - Status: signed - Chamber: Senate - Introduced: 2026-01-07 - Last action: 2026-04-13, Acts of Assembly Chapter text (CHAP0881) - Sponsor: Jeremy S. McPike (Democratic) - Cosponsors: 0 - Touches household money: yes - Roll calls: 10 (260 yes, 1 no in all) - Economic provisions PRIA read: 12 ## 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. ## Bill overview: provisions PRIA read - Fairer treatment for accident lawsuit patients: benefit, medium. Virginia-regulated health plan contracts must bar providers from discriminating solely because a patient has a possible or pending accident lawsuit. Providers are not required to treat patients who threatened or made professional-liability claims or regulatory complaints against them or related peo… - Faster care approvals that insurers honor: benefit, medium. Insurers must respond within 72 hours, including weekends, when delaying advance approval could seriously threaten health or recovery. Standard requests have a seven-calendar-day response deadline. Responses must approve, deny with reasons, or request specific information; completed follow-up infor… - Public approval rules protect patient claims: benefit, low. Insurers must keep services, procedures, codes, and forms requiring advance approval in one public online location. They must update that information when new requirements take effect and notify providers at least 30 calendar days before changes. That notice period does not apply when approval requ… - Limits on recovering past provider payments: benefit, low. Insurers must identify a paid claim, explain any recovery in writing, and give at least 30 days' advance notice. Recovery must be permitted by the provider contract and cannot violate the law's other protections. Allowed grounds include fraud, duplicate payment, services not delivered, or payment m… - Payment protection for previously approved care: benefit, low. Insurers must pay claims for care they approved or said was covered and medically needed. Exceptions include unsupported claims, payment already made or another responsible payer's payment, fraud, material reliance on incorrect information, and previously unknown ineligibility despite reasonable ca… - Providers can challenge lowered billing codes: benefit, low. Insurers or claims agents may lower a claim's billing code only through a person or a system using correct coding standards. The decision must consider relevant patient data documented on the claim, and providers must receive notice and adjustment codes. Contracts must allow at least 180 days after… - Providers get clearer coverage and payment rules: benefit, low. Insurers must let contracted providers check whether services are covered and medically needed, along with approval and payment requirements. Contracts must disclose routine practices for combining billing codes or lowering them to pay less. Applicable policies must be available electronically with… - Timely provider payments with fee-free options: benefit, low. Insurers must pay provider claims within 40 days of receipt, with exceptions for documented disputes or suspected fraud. They must report defects and request needed information within 30 days; otherwise, the claim is treated as complete. Required notices and information must be electronic no later… - Some plans and drugs remain excluded: cost, low. This section's advance-approval rules exclude drugs governed by Virginia's separate drug-approval law. They also exclude qualifying health maintenance organizations using a multispecialty physician group whose doctors are both employees and shareholders. To qualify, the plan must provide or arrange… - Provider remedies include complaint waiting rules: mixed, low. Before complaining to the state about missed 40-day payment deadlines, providers must try to confer and document disputed claims. They must attest to those steps and generally wait 30 calendar days after requesting a conference if the insurer responds. No waiting period applies when the provider ju… - Clearer provider contracts require electronic exchange: mixed, low. Insurers must include applicable fee schedules or payment explanations, material attachments, and policies when offering provider contracts. A clear written explanation can replace a policy when copyright prevents sharing it. Contract changes require at least 60 calendar days' advance notice. Provi… - Electronic care approvals require system upgrades: mixed, low. Insurers must maintain a federally aligned electronic interface for advance approval of medical items and services. Implementation is due January 1, 2027, or a later date set by the federal Centers for Medicare & Medicaid Services. Providers must make their health record or health technology system… ## Sponsors and cosponsors - Sponsor: Jeremy S. McPike (Democratic), Senate ## Roll call votes | Date | Chamber | Motion | Result | Yes | No | Other | | --- | --- | --- | --- | --- | --- | --- | | 2026-03-06 | Senate | House substitute with amendments agreed to by Senate | pass | 40 | 0 | | | 2026-03-04 | House | Passed House with substitute with amendments | pass | 97 | 1 | | | 2026-02-26 | House | Reported from Labor and Commerce with substitute | pass | 21 | 0 | | | 2026-02-24 | House | Subcommittee recommends reporting with substitute | pass | 9 | 0 | | | 2026-01-30 | Senate | Read third time and passed Senate Block Vote | pass | 38 | 0 | | | 2026-01-29 | Senate | Commerce and Labor Substitute agreed to | pass | 0 | 0 | | | 2026-01-29 | Senate | Engrossed by Senate Block Vote (Voice Vote) | pass | 0 | 0 | | | 2026-01-28 | Senate | Passed by for the day Block Vote (Voice Vote) | pass | 0 | 0 | | | 2026-01-28 | Senate | Constitutional reading dispensed Block Vote (on 1st reading) | pass | 40 | 0 | | | 2026-01-26 | Senate | Reported from Commerce and Labor with substitute | pass | 15 | 0 | | ## Actions (45) - 2026-04-13: Acts of Assembly Chapter text (CHAP0881) (Governor) - 2026-04-13: Approved by Governor-Chapter 881 (effective 7/1/2026) (Governor) - 2026-03-24: Fiscal Impact Statement from State Corporation Commission (SB164) (Senate) - 2026-03-14: Governor's Action Deadline 11:59 p.m., April 13, 2026 (Governor) - 2026-03-14: Enrolled Bill communicated to Governor on March 14, 2026 (Senate) - 2026-03-12: Bill text as passed Senate and House (SB164ER) (Senate) - 2026-03-12: Enrolled (Senate) - 2026-03-12: Signed by President (Senate) - 2026-03-12: Signed by Speaker (House) - 2026-03-06: House substitute with amendments agreed to by Senate (40-Y 0-N 0-A) (Senate) - 2026-03-04: Passed House with substitute with amendments (97-Y 1-N 0-A) (House) - 2026-03-04: Engrossed by House - committee substitute as amended (House) - 2026-03-04: Delegate Shin Floor amendments agreed to (House) - 2026-03-04: Labor and Commerce Substituteagreed to by House (House) - 2026-03-04: Reconsideration of (House) - 2026-03-04: Floor Offered (House) - 2026-03-04: Passed by temporarily (House) - 2026-03-04: committee substitute rejected (House) - 2026-03-04: Read third time (House) - 2026-03-03: Fiscal Impact Statement from State Corporation Commission (SB164) (Senate) - 2026-03-03: Passed by for the day (House) - 2026-03-03: Moved from Uncontested Calendar to Regular Calendar (House) - 2026-03-02: Read second time (House) - 2026-02-27: Committee substitute printed 26108190D-H1 (House) - 2026-02-26: Reported from Labor and Commerce with substitute (21-Y 0-N) (House) - 2026-02-24: Subcommittee recommends reporting with substitute (9-Y 0-N) (House) - 2026-02-19: Assigned HCL sub: Subcommittee #1 (House) - 2026-02-04: Referred to Committee on Labor and Commerce (House) - 2026-02-04: Read first time (House) - 2026-02-04: Placed on Calendar (House) - 2026-01-30: Read third time and passed Senate Block Vote (Senate) - 2026-01-29: Engrossed by Senate Block Vote (Voice Vote) (Senate) - 2026-01-29: Commerce and Labor Substitute agreed to (Senate) - 2026-01-29: Engrossed by Senate - committee substitute (Senate) - 2026-01-29: Read second time (Senate) - 2026-01-28: Passed by for the day Block Vote (Voice Vote) (Senate) - 2026-01-28: Constitutional reading dispensed Block Vote (on 1st reading) (40-Y 0-N 0-A) (Senate) - 2026-01-28: Passed by for the day (Senate) - 2026-01-28: Rules suspended (Senate) - 2026-01-27: Committee substitute printed 26106195D-S1 (Senate) - 2026-01-26: Senate committee offered (Senate) - 2026-01-26: Senate committee offered (Senate) - 2026-01-26: Reported from Commerce and Labor with substitute (15-Y 0-N) (Senate) - 2026-01-07: Referred to Committee on Commerce and Labor (Senate) - 2026-01-07: Prefiled and ordered printed; Offered 01-14-2026 26103299D (Senate) ## Bill text - Chaptered, 2026-04-13: [HTML](https://lis.blob.core.windows.net/files/1223052.HTML), [PDF](https://lis.blob.core.windows.net/files/1223051.PDF) - Enrolled, 2026-03-12: [HTML](https://lis.blob.core.windows.net/files/1202609.HTML), [PDF](https://lis.blob.core.windows.net/files/1202608.PDF) - Amendment, 2026-03-04: [HTML](https://lis.blob.core.windows.net/files/1193528.HTML), [HTML](https://lis.blob.core.windows.net/files/1194141.HTML) - Substitute, 2026-02-27: [HTML](https://lis.blob.core.windows.net/files/1185522.HTML), [PDF](https://lis.blob.core.windows.net/files/1185521.PDF) - Substitute, 2026-02-25: [HTML](https://lis.blob.core.windows.net/files/1179342.HTML), [PDF](https://lis.blob.core.windows.net/files/1179341.PDF) - Substitute, 2026-02-24: [HTML](https://lis.blob.core.windows.net/files/1178889.HTML), [PDF](https://lis.blob.core.windows.net/files/1178888.PDF) - Substitute, 2026-01-27: [HTML](https://lis.blob.core.windows.net/files/1097328.HTML), [PDF](https://lis.blob.core.windows.net/files/1097327.PDF) - Substitute, 2026-01-26: [HTML](https://lis.blob.core.windows.net/files/1097057.HTML), [PDF](https://lis.blob.core.windows.net/files/1097056.PDF) - Introduced, 2026-01-07: [HTML](https://lis.blob.core.windows.net/files/1083621.HTML), [PDF](https://lis.blob.core.windows.net/files/1083620.PDF) ## Related bills - HB5: Employment; paid sick leave, civil penalties. (signed) - SB199: Employment; paid sick leave, civil penalties. (signed) - HB95: Va. Residential Landlord and Tenant Act; landlord remedies, noncompliance with rental agreement. (signed) - HB1393: Electric utilities; pilot program for energy assistance and weatherization for certain individuals. (signed) - HB834: Virginia Residential Landlord and Tenant Act; fire or casualty damage, termination by landlord. (signed) - HB675: Protection of employees; coercion or threat based on immigration status, civil penalty. (signed) ## Sources - [Chaptered (HTML)](https://lis.blob.core.windows.net/files/1223052.HTML) - [Chaptered (PDF)](https://lis.blob.core.windows.net/files/1223051.PDF) - [Enrolled (HTML)](https://lis.blob.core.windows.net/files/1202609.HTML) - [Enrolled (PDF)](https://lis.blob.core.windows.net/files/1202608.PDF) - [Amendment (HTML)](https://lis.blob.core.windows.net/files/1193528.HTML) - [Amendment (HTML)](https://lis.blob.core.windows.net/files/1194141.HTML) - [Substitute (HTML)](https://lis.blob.core.windows.net/files/1185522.HTML) - [Substitute (PDF)](https://lis.blob.core.windows.net/files/1185521.PDF) - [Substitute (HTML)](https://lis.blob.core.windows.net/files/1179342.HTML) - [Substitute (PDF)](https://lis.blob.core.windows.net/files/1179341.PDF) - [Substitute (HTML)](https://lis.blob.core.windows.net/files/1178889.HTML) - [Substitute (PDF)](https://lis.blob.core.windows.net/files/1178888.PDF) - [Substitute (HTML)](https://lis.blob.core.windows.net/files/1097328.HTML) - [Substitute (PDF)](https://lis.blob.core.windows.net/files/1097327.PDF) - [Substitute (HTML)](https://lis.blob.core.windows.net/files/1097057.HTML) - [Substitute (PDF)](https://lis.blob.core.windows.net/files/1097056.PDF) - [Introduced (HTML)](https://lis.blob.core.windows.net/files/1083621.HTML) - [Introduced (PDF)](https://lis.blob.core.windows.net/files/1083620.PDF) ## Related - [HB5: Employment; paid sick leave, civil penalties.](https://policyrisk.com/state-bill/VA-HB5-2026) - [SB199: Employment; paid sick leave, civil penalties.](https://policyrisk.com/state-bill/VA-SB199-2026) - [HB95: Va. Residential Landlord and Tenant Act; landlord remedies, noncompliance with…](https://policyrisk.com/state-bill/VA-HB95-2026) - [HB1393: Electric utilities; pilot program for energy assistance and weatherization for…](https://policyrisk.com/state-bill/VA-HB1393-2026) - [HB834: Virginia Residential Landlord and Tenant Act; fire or casualty damage, terminat…](https://policyrisk.com/state-bill/VA-HB834-2026) - [HB675: Protection of employees; coercion or threat based on immigration status, civil…](https://policyrisk.com/state-bill/VA-HB675-2026) - [Virginia bills](https://policyrisk.com/states/virginia/bills) - [Virginia state hub](https://policyrisk.com/states/virginia) - [All state legislation](https://policyrisk.com/state-bills) Source: PRIA, https://policyrisk.com/state-bill/VA-SB164-2026 (as of 2026-10-12).