                                 CODE OF VIRGINIA

DUTY OF IN-NETWORK PROVIDERS TO SUBMIT CLAIMS TO HEALTH INSURERS; LIABILITY OF
COVERED PATIENTS FOR UNBILLED HEALTH CARE SERVICES (§ 8.01-27.5)

A. As used in this section:
			&#8220;Covered patient&#8221; means a patient whose health care services are
covered under terms of a health care policy.
			&#8220;Health care policy&#8221; means any health care plan, subscription
contract, evidence of coverage, certificate, health services plan, medical or
hospital services plan, accident and sickness insurance policy or certificate,
or other similar certificate, policy, contract, or arrangement, and any
endorsement or rider thereto, offered, arranged, issued, or administered by a
health insurer to an individual or a group contract holder to cover all or a
portion of the cost of individuals, or their eligible dependents, receiving
covered health care services. &#8220;Health care policy&#8221; includes
coverages issued pursuant to (i) Chapter 28 (&#xA7; 2.2-2800 et seq.) of Title
2.2 (state employees); (ii) &#xA7; 2.2-1204 (local choice); (iii) 5 U.S.C.
&#xA7; 8901 et seq. (federal employees); (iv) an employee welfare benefit plan
as defined in 29 U.S.C. &#xA7; 1002 (1) of the Employee Retirement Income
Security Act of 1974 (ERISA) that is self-insured or self-funded; and (v) Title
XVIII of the Social Security Act, 42 U.S.C. &#xA7; 1395 et seq. (Medicare),
Title XIX of the Social Security Act, 42 U.S.C. &#xA7; 1396 et seq. (Medicaid),
or Title XXI of the Social Security Act, 42 U.S.C. &#xA7; 1397aa et seq. (CHIP).
&#8220;Health care policy&#8221; does not include (a) Chapter 55 of Title 10 of
the United States Code, 10 U.S.C. &#xA7; 1071 et seq. (TRICARE); (b)
subscription contracts for one or more dental or optometric services plans that
are subject to Chapter 45 (&#xA7; 38.2-4500 et seq.) of Title 38.2; (c)
insurance policies that provide coverage, singly or in combination, for death,
dismemberment, disability, or hospital and medical care caused by or
necessitated as a result of accident or specified kinds of accidents, including
student accident, sports accident, blanket accident, specific accident, and
accidental death and dismemberment policies; (d) credit life insurance and
credit accident and sickness insurance issued pursuant to Chapter 37.1 (&#xA7;
38.2-3717 et seq.) of Title 38.2; (e) insurance policies that provide payments
when an insured is disabled or unable to work because of illness, disease, or
injury, including incidental benefits; (f) long-term care insurance as defined
in &#xA7; 38.2-5200; (g) plans providing only limited health care services under
&#xA7; 38.2-4300 unless offered by endorsement or rider to a group health
benefit plan; (h) TRICARE supplement, Medicare supplement, or workers&#8217;
compensation coverages; or (i) medical expense coverage issued pursuant to
&#xA7; 38.2-2201.
			&#8220;Health care provider&#8221; has the same meaning ascribed to the term
in &#xA7; 8.01-581.1.
			&#8220;Health care services&#8221; means items or services furnished to any
individual for the purpose of preventing, alleviating, curing, or healing human
illness, injury, or physical disability.
			&#8220;Health insurer&#8221; means any entity that is the issuer or sponsor
of a health care policy.
			&#8220;In-network provider&#8221; means a health care provider that is
employed by or has entered into a provider agreement with the health insurer
that has issued the health care policy or is a participating provider with such
health insurer, under which agreement or conditions of participation the health
care provider has agreed to provide health care services to covered patients.
			&#8220;Patient&#8221; means an individual who receives health care services
from a health care provider, or any person authorized by law to consent on
behalf of the individual incapable of making an informed decision, or, in the
case of a minor child, the parent or parents having custody of the child or the
child&#8217;s legal guardian, or as otherwise provided by law.
			&#8220;Provider agreement&#8221; means a contract, agreement, or arrangement
between a health care provider and a health insurer, or a health insurer&#8217;s
network, provider panel, intermediary, or representative, under which the health
care provider has agreed to provide health care services to patients with
coverage under a health care policy issued by the health insurer and to accept
payment from the health insurer for the health care services provided.

B. An in-network provider that provides health care services to a covered
patient shall submit its claim to the health insurer for the health care
services in accordance with the terms of the applicable provider agreement or as
permitted under applicable federal or state laws or regulations, provided that
the covered patient provides the in-network provider with information required
by the terms of the covered patient&#8217;s health care policy&#8217;s plan
documents, including the information that is required to verify the
individual&#8217;s coverage under the health care policy, within not fewer than
21 business days before the deadline for the in-network provider to submit its
claim to the health insurer as required by the terms of the provider agreement.
If an in-network provider does not submit its claim to the health insurer in
accordance with the requirements of this subsection, then (i) the covered
patient shall have no obligation to pay for health care services for which the
in-network provider was required to submit its claim, (ii) the in-network
provider shall not have the benefit of the liens provided by &#xA7;&#xA7;
8.01-66.2 and 8.01-66.9 with regard to health care services for which the
in-network provider was required to submit its claim, and (iii) the in-network
provider shall be prohibited from recovering payment for any of the health care
services for which it was required to submit its claim from an insurer providing
medical expense benefits to the covered patient under a policy of motor vehicle
liability insurance pursuant to &#xA7; 38.2-2201, by exercising an assignment of
the covered patient&#8217;s rights to the medical expense benefits or by other
means. If the in-network provider submits its claim to the health insurer in
accordance with the requirements of this subsection, the covered patient or the
health insurer shall be obligated to pay for the health care services in
accordance with the terms of the provider agreement or health care
policy&#8217;s plan documents. To the extent that self-insured or self-funded
plans governed by ERISA or Title XVIII of the Social Security Act, 42 U.S.C.
&#xA7; 1395 et seq. (Medicare), Title XIX of the Social Security Act, 42 U.S.C.
&#xA7; 1396 et seq. (Medicaid), or Title XXI of the Social Security Act, 42
U.S.C. &#xA7; 1397aa et seq. (CHIP) provide otherwise, health care providers
shall be permitted to submit claims and coordinate benefits as provided for in
the provider agreements or plan documents or as required under applicable
federal and state laws and regulations.

C. Any knowing violation of the provisions of this section shall constitute a
prohibited practice in accordance with &#xA7; 59.1-200 and shall be subject to
any and all of the enforcement provisions of the Virginia Consumer Protection
Act (&#xA7; 59.1-196 et seq.).

HISTORY: 2013, c. 700; 2014, cc. 157, 417; 2018, c. 788; 2022, c. 351.