{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3407.9_03.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3407.9_03.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3407.9_03.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3407.9_03.html"}],"law_id":68601,"edition_id":1,"section_id":68601,"structure_id":12994,"section_number":"38.2-3407.9:03","catch_line":"Payment of clean claims to administrators of pharmacy benefits","history":"2008, c. 104.","full_text":"A\n\nAs used in this section, &#8220;clean claim,&#8221; &#8220;carrier,&#8221; and &#8220;provider contract,&#8221; shall have the meanings set forth in subsection A of &#xA7; 38.2-3407.15.B\n\nAny contract between a carrier and its pharmacy benefits administrator or a carrier and a participating pharmacy, or its contracting agent, that requires claims be submitted electronically shall require that payment be made electronically to the participating provider or its designee for clean claims, as defined in subsection A of &#xA7; 38.2-3407.15, submitted electronically. An electronic claim must be submitted in the form required by the carrier and in compliance with 45 CFR Part 142, as amended, provided that the participating provider or designee agrees to accept claims details for such payments electronically, in compliance with 45 CFR Part 142, as amended, and provides accurate electronic funds transfer information to the carrier.C\n\nThis section shall apply with respect to contracts between a carrier and its pharmacy benefits administrator or a carrier and a pharmacy, or its contracting agent, that are entered into, amended, extended, or renewed on or after January 1, 2009.","order_by":null,"text":{"0":{"id":248301,"text":"As used in this section, &#8220;clean claim,&#8221; &#8220;carrier,&#8221; and &#8220;provider contract,&#8221; shall have the meanings set forth in subsection A of &#xA7; 38.2-3407.15.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":248302,"text":"Any contract between a carrier and its pharmacy benefits administrator or a carrier and a participating pharmacy, or its contracting agent, that requires claims be submitted electronically shall require that payment be made electronically to the participating provider or its designee for clean claims, as defined in subsection A of &#xA7; 38.2-3407.15, submitted electronically. An electronic claim must be submitted in the form required by the carrier and in compliance with 45 CFR Part 142, as amended, provided that the participating provider or designee agrees to accept claims details for such payments electronically, in compliance with 45 CFR Part 142, as amended, and provides accurate electronic funds transfer information to the carrier.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":248303,"text":"This section shall apply with respect to contracts between a carrier and its pharmacy benefits administrator or a carrier and a pharmacy, or its contracting agent, that are entered into, amended, extended, or renewed on or after January 1, 2009.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B"}},"ancestry":[{"id":12994,"edition_id":1,"name":"General Provisions","identifier":"1","label":"article","depth":3,"order_by":1,"parent_id":12993,"metadata":{},"date_created":"2026-06-26 03:44:07","date_modified":"2026-06-26 03:44:07","permalink":{"id":214889,"object_type":"structure","relational_id":12994,"identifier":"1","token":"38.2\/34\/1","url":"\/38.2\/34\/1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12993,"edition_id":1,"name":"Provisions Relating to Accident and Sickness Insurance","identifier":"34","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:44:07","date_modified":"2026-06-26 03:44:07","permalink":{"id":214887,"object_type":"structure","relational_id":12993,"identifier":"34","token":"38.2\/34","url":"\/38.2\/34\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12698,"edition_id":1,"name":"Insurance","identifier":"38.2","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:49","date_modified":"2026-06-26 03:43:49","permalink":{"id":210661,"object_type":"structure","relational_id":12698,"identifier":"38.2","token":"38.2","url":"\/38.2\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":57593,"structure_id":12994,"section_number":"38.2-3400","catch_line":"Application of chapter","url":"\/38.2-3400\/","token":"38.2\/34\/1\/38.2-3400","metadata":false},{"id":72072,"structure_id":12994,"section_number":"38.2-3401","catch_line":"Forms of insurance authorized","url":"\/38.2-3401\/","token":"38.2\/34\/1\/38.2-3401","metadata":false},{"id":65240,"structure_id":12994,"section_number":"38.2-3402","catch_line":"Certification to accompany application","url":"\/38.2-3402\/","token":"38.2\/34\/1\/38.2-3402","metadata":false},{"id":83988,"structure_id":12994,"section_number":"38.2-3403","catch_line":"Fraudulent procurement of policy","url":"\/38.2-3403\/","token":"38.2\/34\/1\/38.2-3403","metadata":false},{"id":65279,"structure_id":12994,"section_number":"38.2-3404","catch_line":"Commission may establish rules and regulations for simplified and readable accident and sickness insurance policies","url":"\/38.2-3404\/","token":"38.2\/34\/1\/38.2-3404","metadata":false},{"id":62539,"structure_id":12994,"section_number":"38.2-3405","catch_line":"Certain subrogation provisions and limitations upon recovery in hospital, medical, etc., policies forbidden; limitations on disclosure of medical treatment options prohibited","url":"\/38.2-3405\/","token":"38.2\/34\/1\/38.2-3405","metadata":false},{"id":84136,"structure_id":12994,"section_number":"38.2-3405.1","catch_line":"Commonwealth's right to certain accident and sickness benefits","url":"\/38.2-3405.1\/","token":"38.2\/34\/1\/38.2-3405.1","metadata":false},{"id":70730,"structure_id":12994,"section_number":"38.2-3406","catch_line":"Accident and sickness benefits not subject to legal process","url":"\/38.2-3406\/","token":"38.2\/34\/1\/38.2-3406","metadata":false},{"id":84333,"structure_id":12994,"section_number":"38.2-3406.1","catch_line":"Application of requirements that policies offered by small employers include state-mandated health benefits","url":"\/38.2-3406.1\/","token":"38.2\/34\/1\/38.2-3406.1","metadata":false},{"id":67972,"structure_id":12994,"section_number":"38.2-3406.2","catch_line":"Capped benefits under insurance policies and contracts","url":"\/38.2-3406.2\/","token":"38.2\/34\/1\/38.2-3406.2","metadata":false},{"id":76321,"structure_id":12994,"section_number":"38.2-3407","catch_line":"Health benefit programs","url":"\/38.2-3407\/","token":"38.2\/34\/1\/38.2-3407","metadata":false},{"id":66921,"structure_id":12994,"section_number":"38.2-3407.1","catch_line":"Interest on accident and sickness claim proceeds","url":"\/38.2-3407.1\/","token":"38.2\/34\/1\/38.2-3407.1","metadata":false},{"id":58079,"structure_id":12994,"section_number":"38.2-3407.10","catch_line":"Health care provider panels","url":"\/38.2-3407.10\/","token":"38.2\/34\/1\/38.2-3407.10","metadata":false},{"id":66411,"structure_id":12994,"section_number":"38.2-3407.10:1","catch_line":"Processing of new provider applications and reimbursement for services rendered during pendency of a participating provider's credentialing application","url":"\/38.2-3407.10_1\/","token":"38.2\/34\/1\/38.2-3407.10_1","metadata":false},{"id":56463,"structure_id":12994,"section_number":"38.2-3407.10:2","catch_line":"Credentialing of private mental health agencies","url":"\/38.2-3407.10_2\/","token":"38.2\/34\/1\/38.2-3407.10_2","metadata":false},{"id":82372,"structure_id":12994,"section_number":"38.2-3407.11","catch_line":"Access to obstetrician-gynecologists","url":"\/38.2-3407.11\/","token":"38.2\/34\/1\/38.2-3407.11","metadata":false},{"id":70024,"structure_id":12994,"section_number":"38.2-3407.11:1","catch_line":"Access to specialists; 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dentists and oral surgeons","url":"\/38.2-3407.13\/","token":"38.2\/34\/1\/38.2-3407.13","metadata":false},{"id":79541,"structure_id":12994,"section_number":"38.2-3407.13:1","catch_line":"Coordination of benefits; notice of priority of coverage","url":"\/38.2-3407.13_1\/","token":"38.2\/34\/1\/38.2-3407.13_1","metadata":false},{"id":87429,"structure_id":12994,"section_number":"38.2-3407.13:2","catch_line":"Claims paid to insureds for services from nonparticipating physicians","url":"\/38.2-3407.13_2\/","token":"38.2\/34\/1\/38.2-3407.13_2","metadata":false},{"id":60288,"structure_id":12994,"section_number":"38.2-3407.14","catch_line":"Notice of premium or deductible increases","url":"\/38.2-3407.14\/","token":"38.2\/34\/1\/38.2-3407.14","metadata":false},{"id":82945,"structure_id":12994,"section_number":"38.2-3407.14:1","catch_line":"Standard of clinical evidence for decisions on coverage for proton radiation therapy","url":"\/38.2-3407.14_1\/","token":"38.2\/34\/1\/38.2-3407.14_1","metadata":false},{"id":71060,"structure_id":12994,"section_number":"38.2-3407.15","catch_line":"Ethics and fairness in carrier business practices","url":"\/38.2-3407.15\/","token":"38.2\/34\/1\/38.2-3407.15","metadata":false},{"id":79973,"structure_id":12994,"section_number":"38.2-3407.15:1","catch_line":"Carrier contracts with pharmacy providers; required provisions; limit on termination or nonrenewal","url":"\/38.2-3407.15_1\/","token":"38.2\/34\/1\/38.2-3407.15_1","metadata":false},{"id":81930,"structure_id":12994,"section_number":"38.2-3407.15:2","catch_line":"(Effective January 1, 2027) Carrier contracts; required provisions regarding prior authorization for drug benefits","url":"\/38.2-3407.15_2\/","token":"38.2\/34\/1\/38.2-3407.15_2","metadata":false},{"id":77493,"structure_id":12994,"section_number":"38.2-3407.15:3","catch_line":"Carrier and intermediary contracts with pharmacy providers; disclosure and updating of maximum allowable cost of drugs; limit on termination or nonrenewal","url":"\/38.2-3407.15_3\/","token":"38.2\/34\/1\/38.2-3407.15_3","metadata":false},{"id":73491,"structure_id":12994,"section_number":"38.2-3407.15:4","catch_line":"Limit on copayment for prescription drugs; permitted disclosures","url":"\/38.2-3407.15_4\/","token":"38.2\/34\/1\/38.2-3407.15_4","metadata":false},{"id":57527,"structure_id":12994,"section_number":"38.2-3407.15:5","catch_line":"Limit on cost-sharing payments for prescription insulin drugs","url":"\/38.2-3407.15_5\/","token":"38.2\/34\/1\/38.2-3407.15_5","metadata":false},{"id":80337,"structure_id":12994,"section_number":"38.2-3407.15:6","catch_line":"Prescription drug price transparency","url":"\/38.2-3407.15_6\/","token":"38.2\/34\/1\/38.2-3407.15_6","metadata":false},{"id":87317,"structure_id":12994,"section_number":"38.2-3407.15:7","catch_line":"Carrier provision of certain information","url":"\/38.2-3407.15_7\/","token":"38.2\/34\/1\/38.2-3407.15_7","metadata":false},{"id":82040,"structure_id":12994,"section_number":"38.2-3407.15:8","catch_line":"(Effective January 1, 2027) Carrier contracts; required provisions regarding prior authorization for health care services","url":"\/38.2-3407.15_8\/","token":"38.2\/34\/1\/38.2-3407.15_8","metadata":false},{"id":76440,"structure_id":12994,"section_number":"38.2-3407.16","catch_line":"Requirements for obstetrical care","url":"\/38.2-3407.16\/","token":"38.2\/34\/1\/38.2-3407.16","metadata":false},{"id":64799,"structure_id":12994,"section_number":"38.2-3407.17","catch_line":"Payment for services by dentists and oral surgeons","url":"\/38.2-3407.17\/","token":"38.2\/34\/1\/38.2-3407.17","metadata":false},{"id":55530,"structure_id":12994,"section_number":"38.2-3407.17:1","catch_line":"Payment and reimbursement practices for dental services; network access","url":"\/38.2-3407.17_1\/","token":"38.2\/34\/1\/38.2-3407.17_1","metadata":false},{"id":81770,"structure_id":12994,"section_number":"38.2-3407.18","catch_line":"Requirements for orally administered cancer chemotherapy drugs","url":"\/38.2-3407.18\/","token":"38.2\/34\/1\/38.2-3407.18","metadata":false},{"id":83502,"structure_id":12994,"section_number":"38.2-3407.19","catch_line":"Payment for services by optometrists and ophthalmologists","url":"\/38.2-3407.19\/","token":"38.2\/34\/1\/38.2-3407.19","metadata":false},{"id":77646,"structure_id":12994,"section_number":"38.2-3407.2","catch_line":"Coverage for medical child support","url":"\/38.2-3407.2\/","token":"38.2\/34\/1\/38.2-3407.2","metadata":false},{"id":73127,"structure_id":12994,"section_number":"38.2-3407.20","catch_line":"Calculation of enrollee's contribution to out-of-pocket maximum or cost-sharing requirement","url":"\/38.2-3407.20\/","token":"38.2\/34\/1\/38.2-3407.20","metadata":false},{"id":57407,"structure_id":12994,"section_number":"38.2-3407.21","catch_line":"Short-term limited-duration medical plans","url":"\/38.2-3407.21\/","token":"38.2\/34\/1\/38.2-3407.21","metadata":false},{"id":85964,"structure_id":12994,"section_number":"38.2-3407.22","catch_line":"Option for rebates to enrollees; 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freedom of choice","url":"\/38.2-3407.7\/","token":"38.2\/34\/1\/38.2-3407.7","metadata":false},{"id":73400,"structure_id":12994,"section_number":"38.2-3407.8","catch_line":"Repealed","url":"\/38.2-3407.8\/","token":"38.2\/34\/1\/38.2-3407.8","metadata":false},{"id":72540,"structure_id":12994,"section_number":"38.2-3407.9","catch_line":"Reimbursement for emergency medical services vehicle transportation services","url":"\/38.2-3407.9\/","token":"38.2\/34\/1\/38.2-3407.9","metadata":false},{"id":62232,"structure_id":12994,"section_number":"38.2-3407.9:01","catch_line":"Prescription drug formularies","url":"\/38.2-3407.9_01\/","token":"38.2\/34\/1\/38.2-3407.9_01","metadata":false},{"id":62074,"structure_id":12994,"section_number":"38.2-3407.9:02","catch_line":"Requirement for prescription drug coverage","url":"\/38.2-3407.9_02\/","token":"38.2\/34\/1\/38.2-3407.9_02","metadata":false},{"id":68601,"structure_id":12994,"section_number":"38.2-3407.9:03","catch_line":"Payment of clean claims to administrators of pharmacy benefits","url":"\/38.2-3407.9_03\/","token":"38.2\/34\/1\/38.2-3407.9_03","metadata":false},{"id":56568,"structure_id":12994,"section_number":"38.2-3407.9:04","catch_line":"Medication synchronization","url":"\/38.2-3407.9_04\/","token":"38.2\/34\/1\/38.2-3407.9_04","metadata":false},{"id":71499,"structure_id":12994,"section_number":"38.2-3407.9:05","catch_line":"Step therapy protocols","url":"\/38.2-3407.9_05\/","token":"38.2\/34\/1\/38.2-3407.9_05","metadata":false}],"previous_section":{"id":62074,"structure_id":12994,"section_number":"38.2-3407.9:02","catch_line":"Requirement for prescription drug coverage","url":"\/38.2-3407.9_02\/","token":"38.2\/34\/1\/38.2-3407.9_02","metadata":false},"next_section":{"id":56568,"structure_id":12994,"section_number":"38.2-3407.9:04","catch_line":"Medication synchronization","url":"\/38.2-3407.9_04\/","token":"38.2\/34\/1\/38.2-3407.9_04","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3407.9:03\/","history_text":"<p>This law was first created in 2008. The record of its establishment is cataloged in chapter <a href=\"https:\/\/legacylis.virginia.gov\/cgi-bin\/legp604.exe?081+ful+CHAP0104\">104<\/a> of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year.<\/p>","references":false,"refers_to":[{"id":71060,"section_number":"38.2-3407.15","catch_line":"Ethics and fairness in carrier business practices","order_by":null,"url":"\/38.2-3407.15\/"}],"permalink":{"id":215131,"object_type":"law","relational_id":68601,"identifier":"38.2-3407.9:03","token":"38.2\/34\/1\/38.2-3407.9_03","url":"\/38.2-3407.9_03\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3407.9_03\/","token":"38.2\/34\/1\/38.2-3407.9_03","dublin_core":{"Title":"Payment of clean claims to administrators of pharmacy benefits","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3407.9:03","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t<section id=\"A\"><p><span class=\"prefix-number\">A.<\/span> As used in this section, &#8220;clean claim,&#8221; &#8220;carrier,&#8221; and &#8220;provider <span class=\"dictionary\">contract<\/span>,&#8221; shall have the meanings set forth in subsection A of &#xA7; <a class=\"law\" title=\"Ethics and fairness in carrier business practices\" href=\"\/38.2-3407.15\/\">38.2-3407.15<\/a>. <a id=\"paragraph-248301\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3407.9_03\/#A\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"B\"><p><span class=\"prefix-number\">B.<\/span> Any <span class=\"dictionary\">contract<\/span> between a carrier and its pharmacy benefits administrator or a carrier and a participating pharmacy, or its contracting agent, that requires claims be submitted electronically shall require that payment be made electronically to the participating provider or its designee for clean claims, as defined in subsection A of &#xA7; <a class=\"law\" title=\"Ethics and fairness in carrier business practices\" href=\"\/38.2-3407.15\/\">38.2-3407.15<\/a>, submitted electronically. An electronic claim must be submitted in the form required by the carrier and in compliance with 45 CFR Part 142, as amended, provided that the participating provider or designee agrees to accept claims details for such payments electronically, in compliance with 45 CFR Part 142, as amended, and provides accurate electronic funds transfer information to the carrier. <a id=\"paragraph-248302\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3407.9_03\/#B\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t<section id=\"C\"><p><span class=\"prefix-number\">C.<\/span> This section shall apply with respect to <span class=\"dictionary\">contracts<\/span> between a carrier and its pharmacy benefits administrator or a carrier and a pharmacy, or its contracting agent, that are entered into, amended, extended, or renewed on or after January 1, 2009. <a id=\"paragraph-248303\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3407.9_03\/#C\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>","plain_text":"                                 CODE OF VIRGINIA\n\nPAYMENT OF CLEAN CLAIMS TO ADMINISTRATORS OF PHARMACY BENEFITS (\u00a7\n38.2-3407.9:03)\n\nA. As used in this section, &#8220;clean claim,&#8221; &#8220;carrier,&#8221;\nand &#8220;provider contract,&#8221; shall have the meanings set forth in\nsubsection A of &#xA7; 38.2-3407.15.\n\nB. Any contract between a carrier and its pharmacy benefits administrator or a\ncarrier and a participating pharmacy, or its contracting agent, that requires\nclaims be submitted electronically shall require that payment be made\nelectronically to the participating provider or its designee for clean claims,\nas defined in subsection A of &#xA7; 38.2-3407.15, submitted electronically. An\nelectronic claim must be submitted in the form required by the carrier and in\ncompliance with 45 CFR Part 142, as amended, provided that the participating\nprovider or designee agrees to accept claims details for such payments\nelectronically, in compliance with 45 CFR Part 142, as amended, and provides\naccurate electronic funds transfer information to the carrier.\n\nC. This section shall apply with respect to contracts between a carrier and its\npharmacy benefits administrator or a carrier and a pharmacy, or its contracting\nagent, that are entered into, amended, extended, or renewed on or after January\n1, 2009.\n\nHISTORY: 2008, c. 104.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}