Virginia's Any Willing Provider Rule for PPOs

Virginia's insurance code contains a short sentence that most states never adopted: "No hospital, physician or type of provider listed in § 38.2-3408 willing to meet the terms and conditions offered to it or him shall be excluded." It applies to preferred provider policies, it reaches far more than physicians, and it comes with an unusual limit on who decides disputes. For a Virginia clinician told a PPO panel is closed, it is the first statute to read.

What does Va. Code 38.2-3407 require?

Section 38.2-3407 lets insurers offer "preferred provider policies or contracts that limit the numbers and types of providers of health care services eligible for payment as preferred providers" (subsection A). Subsection B then sets the conditions:

• The insurer "shall establish terms and conditions that shall be met by a hospital, physician or type of provider listed in § 38.2-3408 in order to qualify for payment as a preferred provider."
• Those terms "shall not discriminate unreasonably against or among such health care providers."
• "No hospital, physician or type of provider listed in § 38.2-3408 willing to meet the terms and conditions offered to it or him shall be excluded."

Subsection B also says price differences from individual negotiation, market conditions or geography are not unreasonable discrimination. Subsection C adds that the mandated provider types in 38.2-3408 "shall, to the extent required by § 38.2-3408, have the same opportunity to qualify for payment as a preferred provider as do doctors of medicine."

Which provider types does it cover?

The list in 38.2-3408(A) is broad. It names licensed chiropractors, optometrists, opticians, professional counselors, psychologists, clinical social workers, podiatrists, physical therapists, chiropodists, clinical nurse specialists, audiologists, speech pathologists, certified nurse midwives or other advanced practice registered nurses, licensed certified midwives, licensed midwives, marriage and family therapists, athletic trainers (in an office setting) and licensed acupuncturists. Hospitals and physicians are named in 38.2-3407(B) itself. Section 38.2-3408 "shall not apply to Medicaid, or any state fund" (38.2-3408(E)).

Who decides a dispute under it?

Not the insurance regulator. The last sentence of 38.2-3407(B) reads: "The Commission shall have no jurisdiction to adjudicate controversies growing out of this subsection." The Commission regulates insurers in Virginia, but a provider's claim of exclusion under this subsection is not something the Commission will decide. That leaves the insurer's own reconsideration process, the business case for contracting, and, if it comes to it, the courts. Whether a refusal violates 38.2-3407(B), and what to do about it, are questions for a Virginia healthcare attorney; we do not answer them.

What does "willing to meet the terms" mean in practice?

The insurer writes the terms. They can include credentialing standards, rates and contract provisions, as long as they do not discriminate unreasonably among providers. So a provider who wants to rely on the statute should:

1. Ask in writing for the terms and conditions the insurer offers to your provider type.
2. Confirm in writing that you are willing to meet them, including the rates.
3. Meet the credentialing requirements and keep the file complete.
4. Ask the insurer to explain any exclusion in light of 38.2-3407(B).

A refusal that rests on "we have enough providers" alone, after you have stated your willingness to meet the offered terms, is the situation the sentence speaks to. A refusal tied to an unmet credentialing requirement is not.

Are there credentialing deadlines in Virginia?

Yes, and they depend on whether a contract already exists.

If the insurer already contracts with you or your employer, Va. Code 38.2-3407.10:1 requires carriers that credential providers to have protocols for new applicants. The carrier must acknowledge receipt (through its online system, or within 10 days by mail or email). Beginning January 1, 2024, an application "is deemed complete within 30 days of the carrier receiving the application, unless the carrier has provided notice that the application is not complete." The carrier "shall approve or deny new provider applicant credentialing applications within 60 days of receiving a completed application." Claims for services during the pending period must be paid within 40 days after the applicant is credentialed and contracted, at the in-network rate (38.2-3407.10:1(B)). These protocols "apply only if a contractual relationship exists between the carrier and the new provider applicant or entity for whom the new provider applicant is employed or engaged." The section does not apply to Medicare Advantage coverage but does apply to Medicaid HMOs (subsection H), and again "The Commission shall have no jurisdiction to adjudicate individual controversies arising out of this section" (subsection I). Before billing for pending-period services, the applicant must give patients the advance written notice in subsection G.

If no contract exists, the Virginia Department of Health's managed care health insurance plan regulations require the plan to notify an applicant within 60 calendar days if information is missing, and to complete credentialing within 90 calendar days of receiving requested information or, if none was requested, within 120 calendar days of receiving the application (12VAC5-408-170(D)(6)).

The same regulation gives applicants a right to review and correct erroneous information obtained in credentialing, subject to exceptions for plan-developed and privileged documents (170(G)); bars refusing to credential "solely because the provider treats a substantial number of patients who require expensive or uncompensated care" (170(I)); and allows provisional credentialing for 60 calendar days for providers who finished residency or fellowship within the prior 12 months (170(B) and (C)).

Where does Virginia's rule not reach?

• Self-funded employer plans, which ERISA generally places outside state insurance law.
• Medicare Advantage, where federal law supersedes state laws on provider inclusion.
• Medicaid, for the 38.2-3408 list, under 38.2-3408(E).
• Coverage other than preferred provider policies. Section 38.2-3407 is written for PPO policies and contracts; check how a particular HMO or exclusive provider product is structured before relying on it.

Our part in a Virginia dispute

We research, prepare and organize, and we are not a law firm. A Network Rejection Review ($249, credited toward a dispute) confirms the product type, your provider type's place on the 38.2-3408 list and which credentialing clock applies. A Payer Network Dispute ($799 per payer) prepares the terms request, the willingness letter, the credentialing corrections and the reconsideration request. You sign and send them; we track replies and deadlines. A contract or credentialing approval carries a flat $1,500 win fee. If you want a legal opinion or court action, a Virginia healthcare attorney is the right call. More state detail is on our Virginia page, and the national picture is in any willing provider laws.