Bill > SB164

This bill aims to enhance fairness and transparency in health insurance carrier business practices, particularly concerning "downcoded claims," which occur when a health insurer reduces the payment for a submitted medical claim without the provider's explicit agreement. The bill prohibits carriers, intermediaries, administrators, or their representatives from downcoding a claim unless the decision is made by a person or an electronic system that considers all relevant patient data provided by the billing provider. Furthermore, if a claim is downcoded, the carrier must notify the submitter, clearly stating the reason for the decision and outlining the process for appealing it, with all dispute decisions ultimately being reviewed and adjudicated by a natural person. The bill also introduces new requirements for electronic prior authorization systems and data reporting, and establishes a work group to monitor the implementation of electronic prior authorization and explore options for improving the prescription drug prior authorization process.

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https://lis.virginia.gov/bill-details/20261/SB164