Health insurance; carrier business practices, method of payment for claims.
SB925 amends Virginia’s health insurance provider-contract rules governing how carriers process, pay, and dispute claims for covered health care services. The bill expands and clarifies the definition of a “clean claim,” requires carriers to pay clean claims within 40 days, and requires carriers to notify providers within 30 days if a claim has defects or missing information. It also requires carriers to maintain proof of claim receipt, pay applicable interest, and, beginning in 2026 for certain notices, move many claim-related communications to electronic delivery.
The bill also adds or strengthens rules on payment methods, prior authorization, bundling and downcoding disclosures, retroactive denials and recoupments, contract amendment notice, dispute review procedures, and provider access to coverage verification. It limits retroactive recovery of previously paid claims to specified circumstances, generally caps recoupment timing at 12 months unless otherwise agreed, and gives providers a private right of action for damages, attorney fees, and potentially treble damages for willful violations. It also prohibits carriers from penalizing providers for asserting rights under the section and requires provider contracts to include certain disclosures and policies.
SB925 updates and reenacts Virginia Code § 38.2-3407.15, which sets minimum fair business standards for health insurers and other carriers in their dealings with providers. The bill affects carrier-provider contracts, claims processing, payment timing, electronic communications, prior authorization practices, and recoupment/retroactive denial procedures. It also gives the State Corporation Commission authority to determine whether carriers have complied with the statutory standards, while preserving limits on the Commission’s jurisdiction over individual disputes. Providers gain additional contractual disclosure rights and enforcement tools, while carriers must adjust contract language, claims systems, and notice practices to comply.
The bill appears to have been broadly supported and noncontroversial in the legislative process. It passed the Senate 40-0 and the House 94-0, and committee reports were unanimous as well, indicating strong bipartisan agreement. The available record shows no recorded opposition in votes or committee action.
No major contention is reflected in the available committee or floor history. The main policy issues embedded in the bill are operational rather than partisan: carriers may object to the added administrative burden of faster payment timelines, mandatory electronic notices, disclosure of bundling/downcoding policies, limits on retroactive denials, and expanded provider remedies. Providers, by contrast, are likely to support the bill’s transparency requirements, payment protections, and enforcement provisions. The bill also includes a specific prohibition on discrimination against enrollees involved in litigation or motor vehicle accidents, but it preserves providers’ ability to refuse treatment in certain professional-liability or complaint-related situations.