                                 CODE OF VIRGINIA

DATA SETS FOR DETERMINING COMMERCIALLY REASONABLE PAYMENTS (§ 38.2-3445.03)

A. 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.

B. 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.

C. 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.

HISTORY: 2020, cc. 1080, 1081.