What is Virginia Prior Authorization Law?
Virginia SB 172 (2020), codified in VA Code §38.2-3407.15:2, establishes timelines for prior authorization decisions. Insurers must respond to standard PA requests within 3 business days and expedited requests within 1 business day. Virginia HB 2013 (2022) further requires carriers to offer electronic prior authorization portals for provider and patient convenience.
Emergency and Expedited Services
Prior authorization is not required for emergency services. Carriers may conduct retrospective review after emergency services are delivered, but cannot deny payment retroactively if the service was medically necessary and the patient acted reasonably in seeking emergency care.
Denial Requirements
When a carrier denies a PA request, they must provide specific clinical criteria that support the denial. Generic denials or denials based solely on missing information (without first requesting that information) violate Virginia law. Patients have the right to know why their request was denied and what clinical standards the carrier applied.
Appeal and Review Rights
- Internal appeal: 30 days from the denial notice
- External review: available through the Virginia State Corporation Commission after internal appeal denial
- State complaint: direct escalation to the SCC for violations
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Frequently Asked Questions
Can a Virginia carrier deny prior authorization without clinical review?
No. Virginia law requires carriers to provide specific clinical criteria for any PA denial. If a carrier denies a PA request, they must explain the clinical reason and cite the standards used. Denials based solely on missing information without requesting it are prohibited.
What is the appeal timeline for a denied prior authorization in Virginia?
Patients have 30 days from the PA denial to file an internal appeal with their carrier. If the internal appeal is denied, external review through the Virginia State Corporation Commission is available.
How to Appeal a Denied Prior Authorization in Virginia
- Document the clinical necessity for the requested treatment — Gather physician notes, test results, and clinical evidence supporting the medical need for the service.
- Submit an internal appeal to your carrier — File your appeal within 30 days of the denial notice, including your clinical documentation and a detailed explanation of why the treatment is medically necessary.
- Request external review through the Virginia State Corporation Commission — If the internal appeal is denied, you may request independent external review through the Virginia SCC.
- Escalate to the SCC if the external review is unfavorable — Contact the Virginia State Corporation Commission directly if you believe your rights have been violated.
Disclaimer: State laws change. This reference is current as of April 13, 2026. Consult Virginia Code §38.2-3407.15:2, HB 2013, or a healthcare attorney for definitive guidance on your specific situation.