{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/65.2-821.1.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/65.2-821.1.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/65.2-821.1.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/65.2-821.1.html"}],"law_id":68923,"edition_id":1,"section_id":68923,"structure_id":13374,"section_number":"65.2-821.1","catch_line":"Payment and reimbursement practices; prohibitions","history":"2016, cc. 279, 290.","full_text":"A\n\nAs used in this section, unless the context requires a different meaning:\n\t\t\t“Contracting entity” means (i) a person that enters into a provider contract with a provider or (ii) an intended beneficiary of the rights of such person under the provider contract.\n\t\t\t“Employer” means the employer; any insurance carrier, group self-insured association, or other person providing coverage for the employer’s obligation to provide medical service to a claimant under this title; or any third-party administrator acting on behalf of the employer.\n\t\t\t“PPO network” means the multiple provider contracts available to an employer pursuant to a PPO network arrangement.\n\t\t\t“PPO network arrangement” means an arrangement under which the PPO network arranger sells, conveys, or otherwise transfers to an employer the ability to discount payments or reimbursements to a provider pursuant to the terms of multiple provider contracts to which the PPO network arranger is a direct party.\n\t\t\t“PPO network arranger” means a person that operates a PPO network arrangement.\n\t\t\t“Provider,” “transition date,” and “Virginia fee schedule” have the meaning assigned thereto in § 65.2-605. “Provider” includes a provider’s employer or professional business entity.\n\t\t\t“Provider contract” means an agreement between a contracting entity and a provider pursuant to which the provider agrees to deliver medical services to a claimant under this title in exchange for payment or reimbursement of an agreed-upon amount.\n\t\t\t“Third-party administrator” means a person that administers, processes, handles, or pays claims to providers on behalf of an employer.B\n\nOn and after the transition date:1\n\nNo employer shall pay or reimburse a provider for medical services provided to a claimant less than the amount provided for in the applicable Virginia fee schedule or other amount determined as provided in subdivision B 2 or 3 of \u00a7 65.2-605 unless:\n\t\t\t\ta. The employer has directly entered into:1\n\nA provider contract with the provider;2\n\nA contract with a contracting entity that has entered into a provider contract with the provider; or3\n\nA contract with a PPO network arranger that authorizes the employer to use a PPO network to derive a benefit from a provider contract; and\n\t\t\t\t\tb. The provider has agreed to provide medical services to the claimant for an agreed-upon reimbursement or contractual amount as set forth in a provider contract referenced in subdivision a.2\n\nA person with whom an employer has directly contracted as described in subdivision 1 a shall not sell, lease, or otherwise disseminate data regarding the payment or reimbursement amounts or terms of a provider contract without the express written consent and prior notification of all parties to the provider contract; however, the express written request from, and prior notification to, a provider shall not be required if the provider’s identity has been redacted from such data.3\n\nIf an employer uses or relies on a contract described in subdivision 1 a to discount a payment or reimbursement to a provider, the employer shall notify the provider, at the time it remits the payment or reimbursement, of (i) the name of the provider, contracting entity, or PPO network arranger with whom the employer directly contracted and (ii) how, if other than by a direct contract between the employer and the provider, the employer acquired the right to discount the payment or reimbursement to the provider.4\n\nIf an employer uses or relies on a contract with a PPO network arranger described in subdivision 1 a (3) to discount a payment or reimbursement to a provider, the employer shall not shop for the lowest discount for a specific provider among the provider contracts held in multiple PPO networks. This prohibition shall not bar an employer that has entered into a PPO network arrangement and selected a provider contract in the PPO network from availing itself of all discounts provided pursuant to the selected provider contract in the PPO network.C\n\nAny person who suffers loss as a result of a violation of this section shall be entitled to initiate an action at the Commission to recover actual damages and interest from the date of the violation until entry of the final award. If the Commission finds that the violation resulted from gross negligence or willful misconduct, it may increase damages to an amount not to exceed three times the actual damages.","order_by":null,"text":{"0":{"id":249529,"text":"As used in this section, unless the context requires a different meaning:\n\t\t\t“Contracting entity” means (i) a person that enters into a provider contract with a provider or (ii) an intended beneficiary of the rights of such person under the provider contract.\n\t\t\t“Employer” means the employer; any insurance carrier, group self-insured association, or other person providing coverage for the employer’s obligation to provide medical service to a claimant under this title; or any third-party administrator acting on behalf of the employer.\n\t\t\t“PPO network” means the multiple provider contracts available to an employer pursuant to a PPO network arrangement.\n\t\t\t“PPO network arrangement” means an arrangement under which the PPO network arranger sells, conveys, or otherwise transfers to an employer the ability to discount payments or reimbursements to a provider pursuant to the terms of multiple provider contracts to which the PPO network arranger is a direct party.\n\t\t\t“PPO network arranger” means a person that operates a PPO network arrangement.\n\t\t\t“Provider,” “transition date,” and “Virginia fee schedule” have the meaning assigned thereto in § 65.2-605. “Provider” includes a provider’s employer or professional business entity.\n\t\t\t“Provider contract” means an agreement between a contracting entity and a provider pursuant to which the provider agrees to deliver medical services to a claimant under this title in exchange for payment or reimbursement of an agreed-upon amount.\n\t\t\t“Third-party administrator” means a person that administers, processes, handles, or pays claims to providers on behalf of an employer.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":249530,"text":"On and after the transition date:","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"B1"},"2":{"id":249531,"text":"No employer shall pay or reimburse a provider for medical services provided to a claimant less than the amount provided for in the applicable Virginia fee schedule or other amount determined as provided in subdivision B 2 or 3 of \u00a7 65.2-605 unless:\n\t\t\t\ta. The employer has directly entered into:","type":"section","prefixes":["B","1"],"prefix":"1","entire_prefix":"B1","prefix_anchor":"B1","level":2,"prior_prefix":"B","next_prefix":"B11"},"3":{"id":249532,"text":"A provider contract with the provider;","type":"section","prefixes":["B","1","1"],"prefix":"1","entire_prefix":"B11","prefix_anchor":"B11","level":3,"prior_prefix":"B1","next_prefix":"B12"},"4":{"id":249533,"text":"A contract with a contracting entity that has entered into a provider contract with the provider; or","type":"section","prefixes":["B","1","2"],"prefix":"2","entire_prefix":"B12","prefix_anchor":"B12","level":3,"prior_prefix":"B11","next_prefix":"B13"},"5":{"id":249534,"text":"A contract with a PPO network arranger that authorizes the employer to use a PPO network to derive a benefit from a provider contract; and\n\t\t\t\t\tb. The provider has agreed to provide medical services to the claimant for an agreed-upon reimbursement or contractual amount as set forth in a provider contract referenced in subdivision a.","type":"section","prefixes":["B","1","3"],"prefix":"3","entire_prefix":"B13","prefix_anchor":"B13","level":3,"prior_prefix":"B12","next_prefix":"B2"},"6":{"id":249535,"text":"A person with whom an employer has directly contracted as described in subdivision 1 a shall not sell, lease, or otherwise disseminate data regarding the payment or reimbursement amounts or terms of a provider contract without the express written consent and prior notification of all parties to the provider contract; however, the express written request from, and prior notification to, a provider shall not be required if the provider’s identity has been redacted from such data.","type":"section","prefixes":["B","2"],"prefix":"2","entire_prefix":"B2","prefix_anchor":"B2","level":2,"prior_prefix":"B13","next_prefix":"B3"},"7":{"id":249536,"text":"If an employer uses or relies on a contract described in subdivision 1 a to discount a payment or reimbursement to a provider, the employer shall notify the provider, at the time it remits the payment or reimbursement, of (i) the name of the provider, contracting entity, or PPO network arranger with whom the employer directly contracted and (ii) how, if other than by a direct contract between the employer and the provider, the employer acquired the right to discount the payment or reimbursement to the provider.","type":"section","prefixes":["B","3"],"prefix":"3","entire_prefix":"B3","prefix_anchor":"B3","level":2,"prior_prefix":"B2","next_prefix":"B4"},"8":{"id":249537,"text":"If an employer uses or relies on a contract with a PPO network arranger described in subdivision 1 a (3) to discount a payment or reimbursement to a provider, the employer shall not shop for the lowest discount for a specific provider among the provider contracts held in multiple PPO networks. This prohibition shall not bar an employer that has entered into a PPO network arrangement and selected a provider contract in the PPO network from availing itself of all discounts provided pursuant to the selected provider contract in the PPO network.","type":"section","prefixes":["B","4"],"prefix":"4","entire_prefix":"B4","prefix_anchor":"B4","level":2,"prior_prefix":"B3","next_prefix":"C"},"9":{"id":249538,"text":"Any person who suffers loss as a result of a violation of this section shall be entitled to initiate an action at the Commission to recover actual damages and interest from the date of the violation until entry of the final award. If the Commission finds that the violation resulted from gross negligence or willful misconduct, it may increase damages to an amount not to exceed three times the actual damages.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B4"}},"ancestry":[{"id":13374,"edition_id":1,"name":"Insurance and Self-Insurance","identifier":"8","label":"chapter","depth":2,"order_by":1,"parent_id":13199,"metadata":{},"date_created":"2026-06-26 03:44:44","date_modified":"2026-06-26 03:44:44","permalink":{"id":276659,"object_type":"structure","relational_id":13374,"identifier":"8","token":"65.2\/8","url":"\/65.2\/8\/","edition_id":1,"permalink":0,"preferred":1}},{"id":13199,"edition_id":1,"name":"Workers' Compensation","identifier":"65.2","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:44:26","date_modified":"2026-06-26 03:44:26","permalink":{"id":276115,"object_type":"structure","relational_id":13199,"identifier":"65.2","token":"65.2","url":"\/65.2\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":68174,"structure_id":13374,"section_number":"65.2-800","catch_line":"Duty to insure payment of compensation; effect of insurance","url":"\/65.2-800\/","token":"65.2\/8\/65.2-800","metadata":false},{"id":60093,"structure_id":13374,"section_number":"65.2-801","catch_line":"Insurance or proof of financial ability to pay required","url":"\/65.2-801\/","token":"65.2\/8\/65.2-801","metadata":false},{"id":85387,"structure_id":13374,"section_number":"65.2-802","catch_line":"Requirements for licensure as group self-insurance association; annual assessment","url":"\/65.2-802\/","token":"65.2\/8\/65.2-802","metadata":false},{"id":72917,"structure_id":13374,"section_number":"65.2-803","catch_line":"Administrator and service company affiliation prohibited; exception","url":"\/65.2-803\/","token":"65.2\/8\/65.2-803","metadata":false},{"id":62818,"structure_id":13374,"section_number":"65.2-803.1","catch_line":"Requirements for registration as professional employer organization; annual assessment","url":"\/65.2-803.1\/","token":"65.2\/8\/65.2-803.1","metadata":false},{"id":58097,"structure_id":13374,"section_number":"65.2-804","catch_line":"Evidence of compliance with title; notices of cancellation of insurance","url":"\/65.2-804\/","token":"65.2\/8\/65.2-804","metadata":false},{"id":83221,"structure_id":13374,"section_number":"65.2-805","catch_line":"Civil penalty for violation of \u00a7\u00a7 65.2-800, 65.2-803.1, and 65.2-804","url":"\/65.2-805\/","token":"65.2\/8\/65.2-805","metadata":false},{"id":72140,"structure_id":13374,"section_number":"65.2-806","catch_line":"Criminal penalties","url":"\/65.2-806\/","token":"65.2\/8\/65.2-806","metadata":false},{"id":54347,"structure_id":13374,"section_number":"65.2-807","catch_line":"Cost of insurance may not be deducted from wages","url":"\/65.2-807\/","token":"65.2\/8\/65.2-807","metadata":false},{"id":77557,"structure_id":13374,"section_number":"65.2-808","catch_line":"Self-insurance certificate","url":"\/65.2-808\/","token":"65.2\/8\/65.2-808","metadata":false},{"id":82374,"structure_id":13374,"section_number":"65.2-809","catch_line":"Constructive notice to, jurisdiction of, and awards, etc., binding upon insurer","url":"\/65.2-809\/","token":"65.2\/8\/65.2-809","metadata":false},{"id":68876,"structure_id":13374,"section_number":"65.2-810","catch_line":"How formal notice may be given","url":"\/65.2-810\/","token":"65.2\/8\/65.2-810","metadata":false},{"id":68761,"structure_id":13374,"section_number":"65.2-811","catch_line":"Liability of insurer","url":"\/65.2-811\/","token":"65.2\/8\/65.2-811","metadata":false},{"id":70340,"structure_id":13374,"section_number":"65.2-812","catch_line":"Subrogation of insurance carrier to employer's rights; compromise","url":"\/65.2-812\/","token":"65.2\/8\/65.2-812","metadata":false},{"id":74334,"structure_id":13374,"section_number":"65.2-813","catch_line":"Insurance deemed subject to title; approval of forms","url":"\/65.2-813\/","token":"65.2\/8\/65.2-813","metadata":false},{"id":67685,"structure_id":13374,"section_number":"65.2-813.1","catch_line":"Insurers offering policies with deductibles","url":"\/65.2-813.1\/","token":"65.2\/8\/65.2-813.1","metadata":false},{"id":81677,"structure_id":13374,"section_number":"65.2-813.2","catch_line":"Premium discounts; drug-free workplace programs","url":"\/65.2-813.2\/","token":"65.2\/8\/65.2-813.2","metadata":false},{"id":62332,"structure_id":13374,"section_number":"65.2-814","catch_line":"Insurer to furnish written evidence of coverage on request","url":"\/65.2-814\/","token":"65.2\/8\/65.2-814","metadata":false},{"id":59696,"structure_id":13374,"section_number":"65.2-815","catch_line":"Group self-insurance association required to furnish written evidence of membership","url":"\/65.2-815\/","token":"65.2\/8\/65.2-815","metadata":false},{"id":77993,"structure_id":13374,"section_number":"65.2-816","catch_line":"Title not applicable to boiler, etc., insurance","url":"\/65.2-816\/","token":"65.2\/8\/65.2-816","metadata":false},{"id":57348,"structure_id":13374,"section_number":"65.2-817","catch_line":"Rates; cooperation between State Corporation Commission and Workers' Compensation Commission","url":"\/65.2-817\/","token":"65.2\/8\/65.2-817","metadata":false},{"id":80112,"structure_id":13374,"section_number":"65.2-818","catch_line":"Minimum standards of service for insurers","url":"\/65.2-818\/","token":"65.2\/8\/65.2-818","metadata":false},{"id":70096,"structure_id":13374,"section_number":"65.2-819","catch_line":"Penalty for violation of certain provisions","url":"\/65.2-819\/","token":"65.2\/8\/65.2-819","metadata":false},{"id":80066,"structure_id":13374,"section_number":"65.2-820","catch_line":"Application to State Corporation Commission for assignment of risk; insurer assigned risk to issue policy","url":"\/65.2-820\/","token":"65.2\/8\/65.2-820","metadata":false},{"id":57462,"structure_id":13374,"section_number":"65.2-821","catch_line":"State Corporation Commission to make rules and regulations, and establish rating schedules and rates","url":"\/65.2-821\/","token":"65.2\/8\/65.2-821","metadata":false},{"id":68923,"structure_id":13374,"section_number":"65.2-821.1","catch_line":"Payment and reimbursement practices; prohibitions","url":"\/65.2-821.1\/","token":"65.2\/8\/65.2-821.1","metadata":false},{"id":65060,"structure_id":13374,"section_number":"65.2-822","catch_line":"Action by State Corporation Commission upon application","url":"\/65.2-822\/","token":"65.2\/8\/65.2-822","metadata":false},{"id":79323,"structure_id":13374,"section_number":"65.2-823","catch_line":"Information filed with State Corporation Commission by insurance carrier to be confidential; exception","url":"\/65.2-823\/","token":"65.2\/8\/65.2-823","metadata":false},{"id":71179,"structure_id":13374,"section_number":"65.2-824","catch_line":"Disclosures not required of State Corporation Commission; liability for acts or omissions","url":"\/65.2-824\/","token":"65.2\/8\/65.2-824","metadata":false}],"previous_section":{"id":57462,"structure_id":13374,"section_number":"65.2-821","catch_line":"State Corporation Commission to make rules and regulations, and establish rating schedules and rates","url":"\/65.2-821\/","token":"65.2\/8\/65.2-821","metadata":false},"next_section":{"id":65060,"structure_id":13374,"section_number":"65.2-822","catch_line":"Action by State Corporation Commission upon application","url":"\/65.2-822\/","token":"65.2\/8\/65.2-822","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/65.2-821.1\/","history_text":"

This law was first created in 2016. The record of its establishment is cataloged in chapters 279<\/a> and 290<\/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":67541,"section_number":"65.2-605","catch_line":"Liability of employer for medical services ordered by Commission; fee schedules for medical services; malpractice; assistants-at-surgery; coding","order_by":null,"url":"\/65.2-605\/"}],"permalink":{"id":276761,"object_type":"law","relational_id":68923,"identifier":"65.2-821.1","token":"65.2\/8\/65.2-821.1","url":"\/65.2-821.1\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/65.2-821.1\/","token":"65.2\/8\/65.2-821.1","dublin_core":{"Title":"Payment and reimbursement practices; prohibitions","Type":"Text","Format":"text\/html","Identifier":"\u00a7 65.2-821.1","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> As used in this section, unless the context requires a different meaning:\n\t\t\t“Contracting entity<\/span>” means (i) a person that enters into a provider contract<\/span> with a provider or (ii) an intended beneficiary of the rights of such person under the provider contract<\/span>.\n\t\t\t“Employer<\/span>” means the employer<\/span>; any insurance carrier, group self-insured association, or other person providing coverage for the employer<\/span>’s obligation to provide medical service to a claimant under this title; or any third-party<\/span> administrator<\/span> acting on behalf of the employer<\/span>.\n\t\t\t“PPO network” means the multiple provider contracts<\/span> available to an employer<\/span> pursuant to a PPO network arrangement<\/span>.\n\t\t\t“PPO network arrangement<\/span>” means an arrangement under which the PPO network arranger<\/span> sells, conveys, or otherwise transfers to an employer<\/span> the ability to discount payments or reimbursements to a provider pursuant to the terms of multiple provider contracts<\/span> to which the PPO network arranger<\/span> is a direct party<\/span>.\n\t\t\t“PPO network arranger<\/span>” means a person that operates a PPO network arrangement<\/span>.\n\t\t\t“Provider,” “transition date,” and “Virginia fee schedule<\/span>” have the meaning assigned thereto in § 65.2-605<\/a>. “Provider” includes a provider’s employer<\/span> or professional business entity.\n\t\t\t“Provider contract<\/span>” means an agreement between a contracting entity<\/span> and a provider pursuant to which the provider agrees to deliver medical services to a claimant under this title in exchange for payment or reimbursement of an agreed-upon amount.\n\t\t\t“Third-party<\/span> administrator<\/span>” means a person that administers, processes, handles, or pays claims to providers<\/span> on behalf of an employer<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> On and after the transition date: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> No employer<\/span> shall pay or reimburse a provider for medical services provided to a claimant less than the amount provided for in the applicable Virginia fee schedule<\/span> or other amount determined as provided in subdivision B 2 or 3 of \u00a7 65.2-605<\/a> unless:\n\t\t\t\ta. The employer<\/span> has directly entered into: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> A provider contract<\/span> with the provider; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> A contract with a contracting entity<\/span> that has entered into a provider contract<\/span> with the provider; or <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> A contract with a PPO network arranger<\/span> that authorizes the employer<\/span> to use a PPO network to derive a benefit from a provider contract<\/span>; and\n\t\t\t\t\tb. The provider has agreed to provide medical services to the claimant for an agreed-upon reimbursement or contractual amount as set forth in a provider contract<\/span> referenced in subdivision a. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> A person with whom an employer<\/span> has directly contracted as described in subdivision 1 a shall not sell, lease, or otherwise disseminate data regarding the payment or reimbursement amounts or terms of a provider contract<\/span> without the express written consent and prior notification of all parties to the provider contract<\/span>; however, the express written request from, and prior notification to, a provider shall not be required if the provider’s identity has been redacted from such data. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> If an employer<\/span> uses or relies on a contract described in subdivision 1 a to discount a payment or reimbursement to a provider, the employer<\/span> shall notify the provider, at the time it remits the payment or reimbursement, of (i) the name of the provider, contracting entity<\/span>, or PPO network arranger<\/span> with whom the employer<\/span> directly contracted and (ii) how, if other than by a direct contract between the employer<\/span> and the provider, the employer<\/span> acquired the right to discount the payment or reimbursement to the provider. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> If an employer<\/span> uses or relies on a contract with a PPO network arranger<\/span> described in subdivision 1 a (3) to discount a payment or reimbursement to a provider, the employer<\/span> shall not shop for the lowest discount for a specific provider among the provider contracts<\/span> held in multiple PPO networks<\/span>. This prohibition shall not bar an employer<\/span> that has entered into a PPO network arrangement<\/span> and selected a provider contract<\/span> in the PPO network from availing itself of all discounts provided pursuant to the selected provider contract<\/span> in the PPO network. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> Any person who suffers loss as a result of a violation of this section shall be entitled to initiate an action at the Commission<\/span> to recover actual damages<\/span> and interest from the date of the violation until entry of the final award<\/span>. If the Commission<\/span> finds that the violation resulted from gross negligence<\/span> or willful misconduct, it may increase damages<\/span> to an amount not to exceed three times the actual damages<\/span>. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nPAYMENT AND REIMBURSEMENT PRACTICES; PROHIBITIONS (\u00a7 65.2-821.1)\n\nA. As used in this section, unless the context requires a different meaning:\n\t\t\t“Contracting entity” means (i) a person that enters into a\nprovider contract with a provider or (ii) an intended beneficiary of the rights\nof such person under the provider contract.\n\t\t\t“Employer” means the employer; any insurance carrier, group\nself-insured association, or other person providing coverage for the\nemployer’s obligation to provide medical service to a claimant under this\ntitle; or any third-party administrator acting on behalf of the employer.\n\t\t\t“PPO network” means the multiple provider contracts available to\nan employer pursuant to a PPO network arrangement.\n\t\t\t“PPO network arrangement” means an arrangement under which the\nPPO network arranger sells, conveys, or otherwise transfers to an employer the\nability to discount payments or reimbursements to a provider pursuant to the\nterms of multiple provider contracts to which the PPO network arranger is a\ndirect party.\n\t\t\t“PPO network arranger” means a person that operates a PPO network\narrangement.\n\t\t\t“Provider,” “transition date,” and “Virginia\nfee schedule” have the meaning assigned thereto in § 65.2-605.\n“Provider” includes a provider’s employer or professional\nbusiness entity.\n\t\t\t“Provider contract” means an agreement between a contracting\nentity and a provider pursuant to which the provider agrees to deliver medical\nservices to a claimant under this title in exchange for payment or reimbursement\nof an agreed-upon amount.\n\t\t\t“Third-party administrator” means a person that administers,\nprocesses, handles, or pays claims to providers on behalf of an employer.\n\nB. On and after the transition date:\n\n 1. No employer shall pay or reimburse a provider for medical services provided\n to a claimant less than the amount provided for in the applicable Virginia fee\n schedule or other amount determined as provided in subdivision B 2 or 3 of \u00a7\n 65.2-605 unless:\n \t\t\t\ta. The employer has directly entered into:\n\n 1. A provider contract with the provider;\n\n 2. A contract with a contracting entity that has entered into a provider\n contract with the provider; or\n\n 3. A contract with a PPO network arranger that authorizes the employer to\n use a PPO network to derive a benefit from a provider contract; and\n \t\t\t\t\tb. The provider has agreed to provide medical services to the claimant\n for an agreed-upon reimbursement or contractual amount as set forth in a\n provider contract referenced in subdivision a.\n\n 2. A person with whom an employer has directly contracted as described in\n subdivision 1 a shall not sell, lease, or otherwise disseminate data regarding\n the payment or reimbursement amounts or terms of a provider contract without\n the express written consent and prior notification of all parties to the\n provider contract; however, the express written request from, and prior\n notification to, a provider shall not be required if the provider’s\n identity has been redacted from such data.\n\n 3. If an employer uses or relies on a contract described in subdivision 1 a to\n discount a payment or reimbursement to a provider, the employer shall notify\n the provider, at the time it remits the payment or reimbursement, of (i) the\n name of the provider, contracting entity, or PPO network arranger with whom\n the employer directly contracted and (ii) how, if other than by a direct\n contract between the employer and the provider, the employer acquired the\n right to discount the payment or reimbursement to the provider.\n\n 4. If an employer uses or relies on a contract with a PPO network arranger\n described in subdivision 1 a (3) to discount a payment or reimbursement to a\n provider, the employer shall not shop for the lowest discount for a specific\n provider among the provider contracts held in multiple PPO networks. This\n prohibition shall not bar an employer that has entered into a PPO network\n arrangement and selected a provider contract in the PPO network from availing\n itself of all discounts provided pursuant to the selected provider contract in\n the PPO network.\n\nC. Any person who suffers loss as a result of a violation of this section shall\nbe entitled to initiate an action at the Commission to recover actual damages\nand interest from the date of the violation until entry of the final award. If\nthe Commission finds that the violation resulted from gross negligence or\nwillful misconduct, it may increase damages to an amount not to exceed three\ntimes the actual damages.\n\nHISTORY: 2016, cc. 279, 290.","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}}