Bill > HB484

This bill aims to ensure fairness and transparency in health insurance carrier business practices, particularly concerning the downcoding of claims. It prohibits health insurance carriers, intermediaries, administrators, or their representatives from "downcoding" a claim—meaning reducing the payment for a service from what the provider billed—unless the decision is made by a person or an electronic system that thoroughly reviews all relevant patient data provided by the billing provider. If a claim is downcoded, the carrier must notify the submitter, clearly stating the reasons for the decision and outlining the process for appealing it. Importantly, any disputes arising from downcoded claims must be resolved by a human being, not solely by an automated system. 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 its expansion to prescription drugs.

Business and Industry

https://lis.virginia.gov/bill-details/20261/HB484