                                 CODE OF VIRGINIA

(EFFECTIVE JANUARY 1, 2027) CARRIER CONTRACTS; REQUIRED PROVISIONS REGARDING
PRIOR AUTHORIZATION FOR HEALTH CARE SERVICES (§ 38.2-3407.15:8)

A. As used in this section:
			&#8220;Carrier&#8221; has the same meaning as provided in subsection A of
&#xA7; 38.2-3407.15.
			&#8220;Expedited&#8221; means, in relation to a health care service or a
prior authorization request for a health care service, that the delay of such
service could seriously jeopardize the enrollee&#8217;s life, health, or ability
to regain maximum function.
			&#8220;Health care services&#8221; has the same meaning as provided in &#xA7;
38.2-3407.15, except that as used in this section, &#8220;health care
services&#8221; does not include drugs that are subject to the requirements of
&#xA7; 38.2-3407.15:2.
			&#8220;Prior authorization&#8221; means the approval process used by a
carrier before certain health care services may be provided.
			&#8220;Provider&#8221; has the same meaning as provided in &#xA7;
38.2-3407.10.
			&#8220;Provider contract&#8221; has the same meaning as provided in
subsection A of &#xA7; 38.2-3407.15.
			&#8220;Standard&#8221; means, in relation to a health care service or a prior
authorization request for a health care service, that such health care service
or prior authorization request is not expedited.
			&#8220;Supplementation&#8221; means a request communicated by the carrier to
the provider or his designee for additional information, limited to items
specifically requested on the applicable prior authorization request, necessary
to approve or deny such request.

B. Any provider contract between a carrier and a participating health care
provider or its contracting agent shall contain specific provisions that:

   1. Require that the carrier communicate electronically or telephonically to
   the provider or his designee within 72 hours, including weekend hours, of
   submission of an expedited prior authorization request to the carrier that the
   request is approved, denied, or requires supplementation;

   2. Require that the carrier communicate electronically or telephonically to
   the provider or his designee within seven calendar days of submission of a
   standard prior authorization request to the carrier that the request is
   approved, denied, or requires supplementation;

   3. Where supplementation is required, require the carrier to specify to the
   provider or his designee the supplementation necessary for the carrier to make
   a final determination that the request is approved or denied, and following
   properly completed supplementation from the provider or his designee, require
   the carrier to approve or deny the request within the timeframes specified in
   subdivisions 1 and 2;

   4. Require that if a prior authorization request is approved for health care
   services and such health care services have been scheduled or provided to the
   enrollee consistent with the authorization, the carrier shall not revoke,
   limit, condition, modify, or restrict that authorization unless (i) the
   provider requests a change, (ii) there is evidence that the authorization was
   obtained based on fraud or misrepresentation, or (iii) a final action by a
   federal regulatory agency or the manufacturer removes an approved health care
   service from the market, limits its use in a manner impacting the prior
   authorization, or communicates a patient safety issue that would impact the
   prior authorization. Nothing in this section shall require a carrier to
   authorize any health care service if the enrollee is no longer enrolled in the
   health plan; and

   5. Require that if the prior authorization request is denied, the carrier
   shall communicate electronically or telephonically to the provider or his
   designee within the timeframes established by subdivision 1 or 2, as
   applicable, the reasons for the denial.

C. If a carrier requires prior authorization for certain health care services to
be covered, the carrier shall make available through one central location on the
carrier&#8217;s publicly accessible website or other electronic application the
list of services and codes for which prior authorization is required. A carrier
must notify providers at least 30 calendar days in advance of the effective date
of any changes to the list of prior authorization requirements and update the
publicly accessible list of services and codes for which prior authorization is
required by the effective date of any new requirement. All of the
carrier&#8217;s prior authorization procedures and all prior authorization
request forms accepted by the carrier shall also be made available and updated
by the carrier on the publicly accessible website or other electronic
application by the effective date of any new requirements. The carrier shall
also indicate the effective date of the prior authorization requirements for
each service on the list, including those services where prior authorization is
performed by an entity under contract with the carrier, provided, however, that
if the prior authorization was already required prior to January 1, 2027, the
carrier may indicate an effective date of January 1, 2027.

D. A carrier shall not deny a claim for failure to obtain prior authorization if
the prior authorization requirements for the date of service were not posted on
the publicly accessible website or other electronic application in accordance
with subsection C.

E. Nothing in this section shall prohibit a carrier from removing prior
authorization requirements without the 30-day notice period to providers in the
event of a pandemic, a natural disaster, or any other emergency situations.

F. Each carrier shall make available by posting on its website no later than
March 31 of each year the prior authorization data for prior authorizations
covered by this section for the previous calendar year at the health plan level
for all metrics required for compliance with federal law and the regulations of
the Centers for Medicare and Medicaid Services, including those promulgated
under 42 C.F.R. &#xA7;&#xA7; 422.122(c), 438.210(f), 440.230(e)(3), and
457.732(c).

G. Notwithstanding any law to the contrary, no provision of this section shall
apply to any health maintenance organization that (i) contracts with a
multispecialty group of physicians who are employed by and are shareholders of
such multispecialty group, which multispecialty group may also contract with
health care providers in the community, and (ii) provides and arranges for the
provision of physician services by the physician members of such multispecialty
group or by such contracted health care providers.

H. The Commission shall have no jurisdiction to adjudicate individual
controversies arising out of this section.

I. Pursuant to the authority granted by &#xA7; 38.2-223, the Commission may
promulgate such rules and regulations as it may deem necessary to implement this
section.

HISTORY: 2025, cc. 58, 68.