House 5379

WEST VIRGINIA LEGISLATURE

2026 REGULAR SESSION

Introduced

House Bill 5379

By Delegates Hite and Petitto

[Introduced February 09, 2026; referred to the Committee on Health and Human Resources then Finance]

A BILL to amend the Code of West Viginia, 1931, as amended, by adding five new sections, designated §33-15-24, §33-16-20, §33-24-46, §33-25-23, and §33-25A-37, relating to requiring insurers to directly pay out-of-network emergency medical services agencies and promptly pay clean claims.

Be it enacted by the Legislature of West Virginia:

ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.

§33-15-24. Requiring direct payment of nonparticipating emergency medical services agencies.

(a) An insurer that receives a clean claim for covered ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency:

(1) Shall remit payment for the ground ambulance services directly to the nonparticipating emergency medical services agency not more than 30 days after receiving the clean claim; and

(2) May not send payment to the covered individual.

(b) An insurer shall pay a clean claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency within 30 days of receipt of the claim, except in the following circumstances:

(1) Another payor or party is responsible for the claim;

(2) The insurer is coordinating benefits with another payor;

(3) The provider has already been paid for the claim;

(4) The claim was submitted fraudulently; or

(5) There was a material misrepresentation in the claim.

(c) If an insurer determines a claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency is not a clean claim, the insurer shall provide written notice within 30 days that:

(1) Acknowledges the date of receipt of the claim; and

(2) States the insurer is declining to pay all or part of the claim and sets forth the specific reason or reasons for declining to pay the claim in full or states additional information is needed to determine whether all or part of the claim is payable and specifically describes the additional information that is needed.

ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.

§33-16-20. Requiring direct payment of nonparticipating emergency medical services agencies.

(a) An insurer that receives a clean claim for covered ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency:

(1) Shall remit payment for the ground ambulance services directly to the nonparticipating emergency medical services agency not more than 30 days after receiving the clean claim; and

(2) May not send payment to the covered individual.

(b) An insurer shall pay a clean claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency within 30 days of receipt of the claim, except in the following circumstances:

(1) Another payor or party is responsible for the claim;

(2) The insurer is coordinating benefits with another payor;

(3) The provider has already been paid for the claim;

(4) The claim was submitted fraudulently; or

(5) There was a material misrepresentation in the claim.

(c) If an insurer determines a claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency is not a clean claim, the insurer shall provide written notice within 30 days that:

(1) Acknowledges the date of receipt of the claim; and

(2) States the insurer is declining to pay all or part of the claim and sets forth the specific reason or reasons for declining to pay the claim in full or states additional information is needed to determine whether all or part of the claim is payable and specifically describes the additional information that is needed.

ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS, DENTAL SERVICE CORPORATIONS AND HEALTH SERVICE CORPORATIONS.

§33-24-46. Requiring direct payment of nonparticipating emergency medical services agencies.

(a) An insurer that receives a clean claim for covered ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency:

(1) Shall remit payment for the ground ambulance services directly to the nonparticipating emergency medical services agency not more than 30 days after receiving the clean claim; and

(2) May not send payment to the covered individual.

(b) An insurer shall pay a clean claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency within 30 days of receipt of the claim, except in the following circumstances:

(1) Another payor or party is responsible for the claim;

(2) The insurer is coordinating benefits with another payor;

(3) The provider has already been paid for the claim;

(4) The claim was submitted fraudulently; or

(5) There was a material misrepresentation in the claim.

(c) If an insurer determines a claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency is not a clean claim, the insurer shall provide written notice within 30 days that:

(1) Acknowledges the date of receipt of the claim; and

(2) States the insurer is declining to pay all or part of the claim and sets forth the specific reason or reasons for declining to pay the claim in full or states additional information is needed to determine whether all or part of the claim is payable and specifically describes the additional information that is needed.

ARTICLE 25. HEALTH CARE CORPORATIONS.

§33-25-23. Requiring direct payment of nonparticipating emergency medical services agencies.

(a) An insurer that receives a clean claim for covered ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency:

(1) Shall remit payment for the ground ambulance services directly to the nonparticipating emergency medical services agency not more than 30 days after receiving the clean claim; and

(2) May not send payment to the covered individual.

(b) An insurer shall pay a clean claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency within 30 days of receipt of the claim, except in the following circumstances:

(1) Another payor or party is responsible for the claim;

(2) The insurer is coordinating benefits with another payor;

(3) The provider has already been paid for the claim;

(4) The claim was submitted fraudulently; or

(5) There was a material misrepresentation in the claim.

(c) If an insurer determines a claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency is not a clean claim, the insurer shall provide written notice within 30 days that:

(1) Acknowledges the date of receipt of the claim; and

(2) States the insurer is declining to pay all or part of the claim and sets forth the specific reason or reasons for declining to pay the claim in full or states additional information is needed to determine whether all or part of the claim is payable and specifically describes the additional information that is needed.

ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.

§33-25A-37. Requiring direct payment of nonparticipating emergency medical services agencies.

(a) An insurer that receives a clean claim for covered ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency:

(1) Shall remit payment for the ground ambulance services directly to the nonparticipating emergency medical services agency not more than 30 days after receiving the clean claim; and

(2) May not send payment to the covered individual.

(b) An insurer shall pay a clean claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency within 30 days of receipt of the claim, except in the following circumstances:

(1) Another payor or party is responsible for the claim;

(2) The insurer is coordinating benefits with another payor;

(3) The provider has already been paid for the claim;

(4) The claim was submitted fraudulently; or

(5) There was a material misrepresentation in the claim.

(c) If an insurer determines a claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency is not a clean claim, the insurer shall provide written notice within 30 days that:

(1) Acknowledges the date of receipt of the claim; and

(2) States the insurer is declining to pay all or part of the claim and sets forth the specific reason or reasons for declining to pay the claim in full or states additional information is needed to determine whether all or part of the claim is payable and specifically describes the additional information that is needed.

NOTE: The purpose of this bill is to require payment by insurers directly to out-of-network emergency medical services agencies and promptly pay clean claims.

Strike-throughs indicate language that would be stricken from a heading or the present law and underscoring indicates new language that would be added.