VA SB164

Requires health insurance carriers to have downcoding decisions (reducing reimbursement codes on claims) made by a natural person or electronic system that considers all relevant patient data, with specific notification to providers including reason codes and a dispute process allowing at least 180 days to contest

Mandates carriers establish and maintain a prior authorization application programming interface (API) by January 1, 2027, aligned with federal Centers for Medicare and Medicaid Services standards for processing prior authorization requests electronically

Requires participating health care providers to ensure their electronic health record systems can access the carrier's prior authorization API within one year of the carrier's implementation deadline, with hardship waivers available

Establishes a work group coordinated by the Bureau of Insurance and Secretary of Health and Human Resources to monitor electronic prior authorization implementation, consider options for prospective prescription drug prior authorization, and evaluate expanding prior authorization metrics reporting to include prescription drugs, with annual reports due through November 1, 2028

Requires carriers to post annual prior authorization data on their websites by March 31 each year, including all metrics required for federal compliance under CMS regulations