An act relating to claim edit standards and prior authorization requirements

This bill modifies Vermont's health insurance claim processing rules. It specifies that standard claim edit requirements (used to review billing accuracy) don't apply when healthcare services are provided outside Vermont, unless the insurer and out-of-state provider agree otherwise. It also updates the definition of "primary care provider" to align with Vermont Blueprint for Health standards, meaning orders from these providers generally won't require prior authorization for in-network services (except for prescriptions or out-of-network care). The changes to claim edits take effect January 1, 2026, while the primary care provider definition change applies immediately.