{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3445.03.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3445.03.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3445.03.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3445.03.html"}],"law_id":57491,"edition_id":1,"section_id":57491,"structure_id":13819,"section_number":"38.2-3445.03","catch_line":"Data sets for determining commercially reasonable payments","history":"2020, cc. 1080, 1081.","full_text":"A\n\nThe Commission shall contract with the nonprofit data services organization to establish a data set and business process to provide health carriers, health care providers, and arbitrators with data to assist in determining commercially reasonable payments and resolving payment disputes for out-of-network medical services rendered by health care providers.B\n\nSuch data set and business protocols shall be (i) developed in collaboration with health carriers and health care providers and (ii) reviewed by the advisory committee established pursuant to &#xA7; 32.1-276.7:1.C\n\nThe data set shall provide the amounts for the services described in subsection A of &#xA7; 38.2-3445.01. The data used to calculate the median in-network and out-of-network allowed amounts and the median billed charge amounts by geographic area, for the same or similar services, shall be drawn from commercial health plan claims and shall not include claims paid under Medicare or Medicaid or other claims paid on other than a fee-for-service basis. The 2020 data set shall be based upon the most recently available full calendar year of claims data. The data set for each subsequent year shall be adjusted by applying the Consumer Price Index-Medical Component as published by the Bureau of Labor Statistics of the U.S. Department of Labor to the previous year&#8217;s data set.","order_by":null,"text":{"0":{"id":210638,"text":"The Commission shall contract with the nonprofit data services organization to establish a data set and business process to provide health carriers, health care providers, and arbitrators with data to assist in determining commercially reasonable payments and resolving payment disputes for out-of-network medical services rendered by health care providers.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":210639,"text":"Such data set and business protocols shall be (i) developed in collaboration with health carriers and health care providers and (ii) reviewed by the advisory committee established pursuant to &#xA7; 32.1-276.7:1.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":210640,"text":"The data set shall provide the amounts for the services described in subsection A of &#xA7; 38.2-3445.01. The data used to calculate the median in-network and out-of-network allowed amounts and the median billed charge amounts by geographic area, for the same or similar services, shall be drawn from commercial health plan claims and shall not include claims paid under Medicare or Medicaid or other claims paid on other than a fee-for-service basis. The 2020 data set shall be based upon the most recently available full calendar year of claims data. The data set for each subsequent year shall be adjusted by applying the Consumer Price Index-Medical Component as published by the Bureau of Labor Statistics of the U.S. Department of Labor to the previous year&#8217;s data set.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B"}},"ancestry":[{"id":13819,"edition_id":1,"name":"Federal Market Reforms","identifier":"6","label":"article","depth":3,"order_by":1,"parent_id":12993,"metadata":{},"date_created":"2026-06-26 03:45:59","date_modified":"2026-06-26 03:45:59","permalink":{"id":215457,"object_type":"structure","relational_id":13819,"identifier":"6","token":"38.2\/34\/6","url":"\/38.2\/34\/6\/","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":57210,"structure_id":13819,"section_number":"38.2-3438","catch_line":"Definitions","url":"\/38.2-3438\/","token":"38.2\/34\/6\/38.2-3438","metadata":false},{"id":55902,"structure_id":13819,"section_number":"38.2-3439","catch_line":"Dependent coverage for individuals to age 26","url":"\/38.2-3439\/","token":"38.2\/34\/6\/38.2-3439","metadata":false},{"id":59514,"structure_id":13819,"section_number":"38.2-3440","catch_line":"Lifetime and annual limits","url":"\/38.2-3440\/","token":"38.2\/34\/6\/38.2-3440","metadata":false},{"id":74720,"structure_id":13819,"section_number":"38.2-3441","catch_line":"Rescissions","url":"\/38.2-3441\/","token":"38.2\/34\/6\/38.2-3441","metadata":false},{"id":81548,"structure_id":13819,"section_number":"38.2-3442","catch_line":"Preventive services","url":"\/38.2-3442\/","token":"38.2\/34\/6\/38.2-3442","metadata":false},{"id":54833,"structure_id":13819,"section_number":"38.2-3443","catch_line":"Choice of a health care professional","url":"\/38.2-3443\/","token":"38.2\/34\/6\/38.2-3443","metadata":false},{"id":68187,"structure_id":13819,"section_number":"38.2-3444","catch_line":"Preexisting condition exclusions","url":"\/38.2-3444\/","token":"38.2\/34\/6\/38.2-3444","metadata":false},{"id":60836,"structure_id":13819,"section_number":"38.2-3445","catch_line":"Patient access to emergency services","url":"\/38.2-3445\/","token":"38.2\/34\/6\/38.2-3445","metadata":false},{"id":57195,"structure_id":13819,"section_number":"38.2-3445.01","catch_line":"Balance billing for certain services; prohibited","url":"\/38.2-3445.01\/","token":"38.2\/34\/6\/38.2-3445.01","metadata":false},{"id":74656,"structure_id":13819,"section_number":"38.2-3445.02","catch_line":"Arbitration","url":"\/38.2-3445.02\/","token":"38.2\/34\/6\/38.2-3445.02","metadata":false},{"id":57491,"structure_id":13819,"section_number":"38.2-3445.03","catch_line":"Data sets for determining commercially reasonable payments","url":"\/38.2-3445.03\/","token":"38.2\/34\/6\/38.2-3445.03","metadata":false},{"id":55717,"structure_id":13819,"section_number":"38.2-3445.04","catch_line":"Transparency","url":"\/38.2-3445.04\/","token":"38.2\/34\/6\/38.2-3445.04","metadata":false},{"id":67926,"structure_id":13819,"section_number":"38.2-3445.05","catch_line":"Enforcement","url":"\/38.2-3445.05\/","token":"38.2\/34\/6\/38.2-3445.05","metadata":false},{"id":66467,"structure_id":13819,"section_number":"38.2-3445.06","catch_line":"Applicability of certain sections","url":"\/38.2-3445.06\/","token":"38.2\/34\/6\/38.2-3445.06","metadata":false},{"id":72898,"structure_id":13819,"section_number":"38.2-3445.07","catch_line":"Rules and regulations","url":"\/38.2-3445.07\/","token":"38.2\/34\/6\/38.2-3445.07","metadata":false},{"id":68114,"structure_id":13819,"section_number":"38.2-3445.1","catch_line":"Repealed","url":"\/38.2-3445.1\/","token":"38.2\/34\/6\/38.2-3445.1","metadata":false},{"id":63588,"structure_id":13819,"section_number":"38.2-3445.2","catch_line":"Out-of-network claims; reporting requirements","url":"\/38.2-3445.2\/","token":"38.2\/34\/6\/38.2-3445.2","metadata":false},{"id":86937,"structure_id":13819,"section_number":"38.2-3446","catch_line":"Applicability of federal law","url":"\/38.2-3446\/","token":"38.2\/34\/6\/38.2-3446","metadata":false},{"id":66501,"structure_id":13819,"section_number":"38.2-3447","catch_line":"(Effective January 1, 2026) Restrictions relating to premium rates","url":"\/38.2-3447\/","token":"38.2\/34\/6\/38.2-3447","metadata":false},{"id":79799,"structure_id":13819,"section_number":"38.2-3448","catch_line":"Guaranteed availability","url":"\/38.2-3448\/","token":"38.2\/34\/6\/38.2-3448","metadata":false},{"id":78815,"structure_id":13819,"section_number":"38.2-3449","catch_line":"Prohibiting discrimination based on health status","url":"\/38.2-3449\/","token":"38.2\/34\/6\/38.2-3449","metadata":false},{"id":67706,"structure_id":13819,"section_number":"38.2-3449.1","catch_line":"Prohibited discrimination based on gender identity or status as a transgender individual","url":"\/38.2-3449.1\/","token":"38.2\/34\/6\/38.2-3449.1","metadata":false},{"id":64622,"structure_id":13819,"section_number":"38.2-3450","catch_line":"Genetic information and testing","url":"\/38.2-3450\/","token":"38.2\/34\/6\/38.2-3450","metadata":false},{"id":83154,"structure_id":13819,"section_number":"38.2-3451","catch_line":"Essential health benefits","url":"\/38.2-3451\/","token":"38.2\/34\/6\/38.2-3451","metadata":false},{"id":76537,"structure_id":13819,"section_number":"38.2-3452","catch_line":"Waiting periods","url":"\/38.2-3452\/","token":"38.2\/34\/6\/38.2-3452","metadata":false},{"id":86395,"structure_id":13819,"section_number":"38.2-3453","catch_line":"Clinical trials","url":"\/38.2-3453\/","token":"38.2\/34\/6\/38.2-3453","metadata":false},{"id":81951,"structure_id":13819,"section_number":"38.2-3454","catch_line":"Wellness programs","url":"\/38.2-3454\/","token":"38.2\/34\/6\/38.2-3454","metadata":false},{"id":84250,"structure_id":13819,"section_number":"38.2-3454.1","catch_line":"Renewal of health benefit plans; special exception","url":"\/38.2-3454.1\/","token":"38.2\/34\/6\/38.2-3454.1","metadata":false}],"previous_section":{"id":74656,"structure_id":13819,"section_number":"38.2-3445.02","catch_line":"Arbitration","url":"\/38.2-3445.02\/","token":"38.2\/34\/6\/38.2-3445.02","metadata":false},"next_section":{"id":55717,"structure_id":13819,"section_number":"38.2-3445.04","catch_line":"Transparency","url":"\/38.2-3445.04\/","token":"38.2\/34\/6\/38.2-3445.04","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3445.03\/","history_text":"<p>This law was first created in 2020. The record of its establishment is cataloged in chapters <a href=\"https:\/\/legacylis.virginia.gov\/cgi-bin\/legp604.exe?201+ful+CHAP1080\">1080<\/a> and <a href=\"https:\/\/legacylis.virginia.gov\/cgi-bin\/legp604.exe?201+ful+CHAP1081\">1081<\/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":[{"id":74656,"section_number":"38.2-3445.02","catch_line":"Arbitration","order_by":null,"url":"\/38.2-3445.02\/"}],"refers_to":[{"id":57195,"section_number":"38.2-3445.01","catch_line":"Balance billing for certain services; prohibited","order_by":null,"url":"\/38.2-3445.01\/"}],"permalink":{"id":215499,"object_type":"law","relational_id":57491,"identifier":"38.2-3445.03","token":"38.2\/34\/6\/38.2-3445.03","url":"\/38.2-3445.03\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3445.03\/","token":"38.2\/34\/6\/38.2-3445.03","dublin_core":{"Title":"Data sets for determining commercially reasonable payments","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3445.03","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t<section id=\"A\"><p><span class=\"prefix-number\">A.<\/span> The <span class=\"dictionary\">Commission<\/span> shall <span class=\"dictionary\">contract<\/span> with the nonprofit data services organization to establish a data set and business process to provide health carriers, health care providers, and arbitrators with data to assist in determining commercially reasonable payments and resolving payment disputes for out-of-network medical services rendered by health care providers. <a id=\"paragraph-210638\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3445.03\/#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> Such data set and business protocols shall be (i) developed in collaboration with health carriers and health care providers and (ii) reviewed by the advisory committee established pursuant to &#xA7; <a class=\"law\" title=\"All-Payer Claims Database created; purpose; reporting requirements\" href=\"\/32.1-276.7_1\/\">32.1-276.7:1<\/a>. <a id=\"paragraph-210639\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3445.03\/#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> The data set shall provide the amounts for the services described in subsection A of &#xA7; <a class=\"law\" title=\"Balance billing for certain services; prohibited\" href=\"\/38.2-3445.01\/\">38.2-3445.01<\/a>. The data used to calculate the median in-network and out-of-network allowed amounts and the median billed charge amounts by geographic area, for the same or similar services, shall be drawn from commercial health plan claims and shall not include claims paid under <span class=\"dictionary\">Medicare<\/span> or Medicaid or other claims paid on other than a fee-for-service basis. The 2020 data set shall be based upon the most recently available full calendar year of claims data. The data set for each subsequent year shall be adjusted by applying the Consumer Price Index-Medical Component as published by the <span class=\"dictionary\">Bureau<\/span> of Labor Statistics of the U.S. Department of Labor to the previous year&#8217;s data set. <a id=\"paragraph-210640\" class=\"section-permalink\" href=\"https:\/\/vacode.org\/38.2-3445.03\/#C\"><i class=\"fa fa-link\"><\/i><\/a><\/p><\/section>","plain_text":"                                 CODE OF VIRGINIA\n\nDATA SETS FOR DETERMINING COMMERCIALLY REASONABLE PAYMENTS (\u00a7 38.2-3445.03)\n\nA. The Commission shall contract with the nonprofit data services organization\nto establish a data set and business process to provide health carriers, health\ncare providers, and arbitrators with data to assist in determining commercially\nreasonable payments and resolving payment disputes for out-of-network medical\nservices rendered by health care providers.\n\nB. Such data set and business protocols shall be (i) developed in collaboration\nwith health carriers and health care providers and (ii) reviewed by the advisory\ncommittee established pursuant to &#xA7; 32.1-276.7:1.\n\nC. The data set shall provide the amounts for the services described in\nsubsection A of &#xA7; 38.2-3445.01. The data used to calculate the median\nin-network and out-of-network allowed amounts and the median billed charge\namounts by geographic area, for the same or similar services, shall be drawn\nfrom commercial health plan claims and shall not include claims paid under\nMedicare or Medicaid or other claims paid on other than a fee-for-service basis.\nThe 2020 data set shall be based upon the most recently available full calendar\nyear of claims data. The data set for each subsequent year shall be adjusted by\napplying the Consumer Price Index-Medical Component as published by the Bureau\nof Labor Statistics of the U.S. Department of Labor to the previous year&#8217;s\ndata set.\n\nHISTORY: 2020, cc. 1080, 1081.","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}}