Virginia legislation · 2026 Regular Session
Virginia SB164: An Act to amend and reenact §§ 38.2-3407.15 and 38.2-3407.15:8, as it shall become effective, of the Code of Virginia and to amend and reenact the second enactment of Chapter 474 and the second enactment of Chapter 475 of the Acts of Assembly of 2023, relating to health insurance; ethics and fairness in carrier business practices; downcoded claims; prior authorization; required contract provisions.
Status: Chaptered, April 13, 2026
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. This bill is identical to HB 484.
What the bill says
An Act to amend and reenact §§ 38.2-3407.15 and 38.2-3407.15:8, as it shall become effective, of the Code of Virginia and to amend and reenact the second enactment of Chapter 474 and the second enactment of Chapter 475 of the Acts of Assembly of 2023, relating to health insurance; ethics and fairness in carrier business practices; downcoded claims; prior authorization; required contract provisions. [S 164] Approved April 13, 2026 1. That §§ 38.2-3407.15 and 38.2-3407.15:8, as it shall become effective, of the Code of Virginia are amended and reenacted as follows: § 38.2-3407.15. Ethics and fai.
From the enrolled text, April 13, 2026:
An Act to amend and reenact §§ 38.2-3407.15 and 38.2-3407.15:8, as it shall become effective, of the Code of Virginia and to amend and reenact the second enactment of Chapter 474 and the second enactment of Chapter 475 of the Acts of Assembly of 2023, relating to health insurance; ethics and fairness in carrier business practices; downcoded claims; prior authorization; required contract provisions. [S 164] Approved April 13, 2026 1. That §§ 38.2-3407.15 and 38.2-3407.15:8, as it shall become effective, of the Code of Virginia are amended and reenacted as follows: § 38.2-3407.15. Ethics and fairness in carrier business practices. A. As used in this however, a "carrier" shall also include any person required to be licensed under this title which offers or operates a managed care health insurance plan subject to Chapter 58 (§ 38.2-5800 et seq.) or which provides or arranges for the provision of health care services, health plans, networks or provider panels which are subject to regulation as the business of insurance under this title. "Claim" means any bill, claim, or proof of loss made by or on behalf of an enrollee or a provider to a carrier (or its intermediary, administrator or representative) with which the provider has a provider contract for payment for health care services under any health plan; however, a "claim" shall …