Virginia HB 1526: Health insurance; prior authorization, required contract provisions.

Bill Text

2026 SESSION

INTRODUCED

26106004D

HOUSE BILL NO. 1526

Offered January 28, 2026

A BILL to amend and reenact § 38.2-3407.15:8, as it shall become effective, of the Code of Virginia and to amend and reenact the second enactment of Chapters 474 and 475 of the Acts of Assembly of 2023, relating to health insurance; prior authorization; required contract provisions.

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Patron—Fowler

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Unanimous consent to introduce

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Referred to Committee on Labor and Commerce

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Be it enacted by the General Assembly of Virginia:

1. That § 38.2-3407.15:8, as it shall become effective, of the Code of Virginia is amended and reenacted as follows:

§ 38.2-3407.15:8. (Effective January 1, 2027) Carrier contracts; required provisions regarding prior authorization for health care services.

A. As used in this section:

"Carrier" has the same meaning as provided in subsection A of § 38.2-3407.15.

"Expedited" 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's life, health, or ability to regain maximum function.

"Health care services" has the same meaning as provided in § 38.2-3407.15, except that as used in this section, "health means items or services furnished to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability, including medical items and services. "Health care services" does not include drugs that are subject to the requirements of § 38.2-3407.15:2.

"Prior authorization" means the approval process used by a carrier before certain health care services may be provided.

"Provider" has the same meaning as provided in § 38.2-3407.10.

"Provider contract" has the same meaning as provided in subsection A of § 38.2-3407.15.

"Standard" 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.

"Supplementation" 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;

6. Require a carrier to establish and maintain a prior authorization application program interface as described in 42 C.F.R. § 422.122(b) for processing prior authorization requests from providers for medical items and services that aligns with the requirements and standards for impacted payers under plan and product types regulated by the U.S. Centers for Medicare and Medicaid Services. A carrier shall implement such prior authorization application program interface by