USA Statutes : nevada
Title : Title 57 - INSURANCE
Chapter : CHAPTER 695G - MANAGED CARE
As used in this chapter, unless the
context otherwise requires, the words and terms defined in NRS 695G.020
to 695G.080 , inclusive, have the meanings ascribed to
them in those sections.
(Added to NRS by 1997, 301; A 2003, 783 )
“Adverse
determination” means a determination of a managed care organization to
deny all or part of a service or procedure that is proposed or being
provided to an insured on the basis that it is not medically necessary or
appropriate or is experimental or investigational. The term does not
include a determination of a managed care organization that such an
allocation is not a covered benefit.
(Added to NRS by 2003, 779 )
“Authorized
representative” means a person who has obtained the consent of an insured
to represent him in an external review of a final adverse determination
conducted pursuant to NRS 695G.241 to
695G.310 , inclusive.
(Added to NRS by 2003, 779 )
“Clinical peer” means a
physician who is:
1. Engaged in the practice of medicine; and
2. Certified or is eligible for certification by a member board of
the American Board of Medical Specialties in the same or similar area of
practice as is the health care service that is the subject of a final
adverse determination.
(Added to NRS by 2003, 779 )
“External
review organization” means an organization that:
1. Conducts an external review of a final adverse determination;
and
2. Is certified by the Commissioner in accordance with NRS
683A.371 .
(Added to NRS by 2003, 779 )
“Health care plan” means
a policy, contract, certificate or agreement offered or issued by a
managed care organization to provide, deliver, arrange for, pay for or
reimburse any of the costs of health care services.
(Added to NRS by 1997, 301)
“Insured” means a person who
receives benefits under a health care plan.
(Added to NRS by 1997, 301)
“Managed care” means a
system for delivering health care services that encourages the efficient
use of health care services by using employed or independently contracted
providers of health care and by using various techniques which may
include, without limitation:
1. Managing the health care services of an insured who has a
serious, complicated, protracted or other health-related condition that
requires the use of numerous providers of health care or other costly
services;
2. Providing utilization review;
3. Offering financial incentives for the effective use of health
care services; or
4. Any combination of those techniques.
(Added to NRS by 1997, 301)
“Managed care
organization” means any insurer or organization authorized pursuant to
this title to conduct business in this State that provides or arranges
for the provision of health care services through managed care.
(Added to NRS by 1997, 302)
“Medically necessary”
means health care services or products that a prudent physician would
provide to a patient to prevent, diagnose or treat an illness, injury or
disease, or any symptoms thereof, that are necessary and:
1. Provided in accordance with generally accepted standards of
medical practice;
2. Clinically appropriate with regard to type, frequency, extent,
location and duration;
3. Not primarily provided for the convenience of the patient,
physician or other provider of health care;
4. Required to improve a specific health condition of an insured
or to preserve his existing state of health; and
5. The most clinically appropriate level of health care that may
be safely provided to the insured.
(Added to NRS by 2003, 779 )
“Primary care
physician” means a physician or group of physicians who:
1. Provides initial and primary health care services to an insured;
2. Maintains the continuity of care for the insured; and
3. May refer the insured to a specialized provider of health care.
(Added to NRS by 1997, 302)
“Provider of
health care” means any physician, hospital or other person who is
licensed or otherwise authorized in this State to furnish any health care
service.
(Added to NRS by 1997, 302)
1. “Utilization review” means the various methods that may be used
by a managed care organization to review the amount and appropriateness
of the provision of a specific health care service to an insured.
2. The term does not include an external review of a final adverse
determination conducted pursuant to NRS 695G.241 to 695G.310 , inclusive.
(Added to NRS by 1997, 302; A 2003, 783 )
1. Except as otherwise provided in subsection 3, the provisions of
this chapter apply to each organization and insurer that operates as a
managed care organization and may include, without limitation, an insurer
that issues a policy of health insurance, an insurer that issues a policy
of individual or group health insurance, a carrier serving small
employers, a fraternal benefit society, a hospital or medical service
corporation and a health maintenance organization.
2. In addition to the provisions of this chapter, each managed
care organization shall comply with:
(a) The provisions of chapter 686A of
NRS, including all obligations and remedies set forth therein; and
(b) Any other applicable provision of this title.
3. The provisions of NRS 695G.164 , 695G.200 to 695G.230 , inclusive, and 695G.430 do not apply to a managed care organization
that provides health care services to recipients of Medicaid under the
State Plan for Medicaid or insurance pursuant to the Children’s Health
Insurance Program pursuant to a contract with the Division of Health Care
Financing and Policy of the Department of Health and Human Services. This
subsection does not exempt a managed care organization from any provision
of this chapter for services provided pursuant to any other contract.
(Added to NRS by 1997, 302; A 2003, 783 , 3371 )
A managed care organization may,
subject to regulation by the Commissioner, offer a policy of health
insurance that has a high deductible and is in compliance with 26 U.S.C.
§ 223 for the purposes of establishing a health savings account.
(Added to NRS by 2005, 2159 )
Any document
required to be filed with the Commissioner pursuant to this chapter,
other than medical records and other information relating to a specific
insured, must be treated as a public record.
(Added to NRS by 1997, 307)
ADMINISTRATION OF MANAGED CARE ORGANIZATIONS
Each managed care organization shall employ or contract with a
physician who is licensed to practice medicine in the State of Nevada
pursuant to chapter 630 or 633 of NRS to serve as its medical director.
(Added to NRS by 1997, 305; A 2003, 1181 )
Each managed care organization shall:
1. Develop and maintain written policies and procedures setting
forth the manner in which it conducts utilization review; and
2. Require any person with whom it subcontracts to provide
utilization review to use the same policies and procedures developed
pursuant to subsection 1.
(Added to NRS by 1997, 303)
1. A managed care organization that delivers health care services
by using independently contracted providers of health care shall use its
best efforts to contract with at least one health center in each
geographic area served by the organization to provide such services to
insureds if the health center:
(a) Meets all conditions imposed by the organization on similarly
situated providers of health care that are under contract with the
organization, including, without limitation:
(1) Certification for participation in the Medicaid or
Medicare program; and
(2) Requirements relating to the appropriate credentials for
providers of health care; and
(b) Agrees to reasonable reimbursement rates that are generally
consistent with those offered by the organization to similarly situated
providers of health care that are under contract with the organization.
2. As used in this section, “health center” has the meaning
ascribed to it in 42 U.S.C. § 254b.
(Added to NRS by 2001, 1925 )
1. In addition to any other report which is required to be filed
with the Commissioner or the State Board of Health, each managed care
organization shall file with the Commissioner and the State Board of
Health, on or before March 1 of each year, a report regarding its methods
for reviewing the quality of health care services provided to its
insureds.
2. Each managed care organization shall include in its report the
criteria, data, benchmarks or studies used to:
(a) Assess the nature, scope, quality and accessibility of health
care services provided to insureds; or
(b) Determine any reduction or modification of the provision of
health care services to insureds.
3. Except as already required to be filed with the Commissioner or
the State Board of Health, if the managed care organization is not owned
and operated by a public entity and has more than 100 insureds, the
report filed pursuant to subsection 1 must include:
(a) A copy of all of its quarterly and annual financial reports;
(b) A statement of any financial interest it has in any other
business which is related to health care that is greater than 5 percent
of that business or $5,000, whichever is less; and
(c) A description of each complaint filed with or against it that
resulted in arbitration, a lawsuit or other legal proceeding, unless
disclosure is prohibited by law or a court order.
4. A report filed pursuant to this section must be made available
for public inspection within a reasonable time after it is received by
the Commissioner.
(Added to NRS by 1997, 305; A 1997, 3041)
Any person who receives, collects, disburses or invests money
for a managed care organization is responsible for such money in a
fiduciary relationship to the insured.
(Added to NRS by 1997, 305)
COVERAGE BY MANAGED CARE ORGANIZATIONS
Each managed care organization shall authorize
coverage of a health care service that has been recommended for the
insured by a provider of health care acting within the scope of his
practice if that service is covered by the health care plan of the
insured, unless:
1. The decision not to authorize coverage is made by a physician
who:
(a) Is licensed to practice medicine in the State of Nevada
pursuant to chapter 630 or 633 of NRS;
(b) Possesses the education, training and expertise to evaluate the
medical condition of the insured; and
(c) Has reviewed the available medical documentation, notes of the
attending physician, test results and other relevant medical records of
the insured.
Ê The physician may consult with other providers of health care in
determining whether to authorize coverage.
2. The decision not to authorize coverage and the reason for the
decision have been transmitted in writing in a timely manner to the
insured, the provider of health care who recommended the service and the
primary care physician of the insured, if any.
(Added to NRS by 1997, 302; A 2003, 1181 )
1. Each managed care organization shall establish written criteria:
(a) Setting forth the manner in which it determines whether to
authorize coverage of a health care service; and
(b) Setting forth its method for reviewing standards for the
quality of health care services provided to an insured.
2. Such written criteria must be:
(a) Developed with the assistance of practicing providers of health
care;
(b) Developed using generally recognized and, if appropriate,
specialized clinical principles and processes;
(c) Reviewed at least one time each year and, if appropriate,
updated; and
(d) Made available to an insured for review upon request of the
insured any time that the managed care organization denies coverage of a
specific health care service to the insured.
(Added to NRS by 1997, 302)
1. A managed care organization that offers or issues a health care
plan which provides coverage for prescription drugs shall include with
any summary, certificate or evidence of that coverage provided to an
insured, notice of whether a formulary is used and, if so, of the
opportunity to secure information regarding the formulary from the
organization pursuant to subsection 2. The notice required by this
subsection must:
(a) Be in a language that is easily understood and in a format that
is easy to understand;
(b) Include an explanation of what a formulary is; and
(c) If a formulary is used, include:
(1) An explanation of:
(I) How often the contents of the formulary are
reviewed; and
(II) The procedure and criteria for determining which
prescription drugs are included in and excluded from the formulary; and
(2) The telephone number of the organization for making a
request for information regarding the formulary pursuant to subsection 2.
2. If a managed care organization offers or issues a health care
plan which provides coverage for prescription drugs and a formulary is
used, the organization shall:
(a) Provide to any insured or participating provider of health
care, upon request:
(1) Information regarding whether a specific drug is
included in the formulary.
(2) Access to the most current list of prescription drugs in
the formulary, organized by major therapeutic category, with an
indication of whether any listed drugs are preferred over other listed
drugs. If more than one formulary is maintained, the organization shall
notify the requester that a choice of formulary lists is available.
(b) Notify each person who requests information regarding the
formulary, that the inclusion of a drug in the formulary does not
guarantee that a provider of health care will prescribe that drug for a
particular medical condition.
(Added to NRS by 2001, 866 )
1. The provisions of this section apply to a health care plan
offered or issued by a managed care organization if an insured covered by
the health care plan receives health care through a defined set of
providers of health care who are under contract with the managed care
organization.
2. Except as otherwise provided in this section, if an insured who
is covered by a health care plan described in subsection 1 is receiving
medical treatment for a medical condition from a provider of health care
whose contract with the managed care organization is terminated during
the course of the medical treatment, the health care plan must provide
that:
(a) The insured may continue to obtain medical treatment for the
medical condition from the provider of health care pursuant to this
section, if:
(1) The insured is actively undergoing a medically necessary
course of treatment; and
(2) The provider of health care and the insured agree that
the continuity of care is desirable.
(b) The provider of health care is entitled to receive
reimbursement from the managed care organization for the medical
treatment he provides to the insured pursuant to this section, if the
provider of health care agrees:
(1) To provide medical treatment under the terms of the
contract between the provider of health care and the managed care
organization with regard to the insured, including, without limitation,
the rates of payment for providing medical service, as those terms
existed before the termination of the contract between the provider of
health care and the managed care organization; and
(2) Not to seek payment from the insured for any medical
service provided by the provider of health care that the provider of
health care could not have received from the insured were the provider of
health care still under contract with the managed care organization.
3. The coverage required by subsection 2 must be provided until
the later of:
(a) The 120th day after the date the contract is terminated; or
(b) If the medical condition is pregnancy, the 45th day after:
(1) The date of delivery; or
(2) If the pregnancy does not end in delivery, the date of
the end of the pregnancy.
4. The requirements of this section do not apply to a provider of
health care if:
(a) The provider of health care was under contract with the managed
care organization and the managed care organization terminated that
contract because of the medical incompetence or professional misconduct
of the provider of health care; and
(b) The managed care organization did not enter into another
contract with the provider of health care after the contract was
terminated pursuant to paragraph (a).
5. An evidence of coverage for a health care plan subject to the
provisions of this chapter that is delivered, issued for delivery or
renewed on or after October 1, 2003, has the legal effect of including
the coverage required by this section, and any provision of the evidence
of coverage or renewal thereof that is in conflict with this section is
void.
6. The Commissioner shall adopt regulations to carry out the
provisions of this section.
(Added to NRS by 2003, 3370 )
1. Except as otherwise provided in this section, a health care
plan which provides coverage for prescription drugs must not limit or
exclude coverage for a drug if the drug:
(a) Had previously been approved for coverage by the managed care
organization for a medical condition of an insured and the insured’s
provider of health care determines, after conducting a reasonable
investigation, that none of the drugs which are otherwise currently
approved for coverage are medically appropriate for the insured; and
(b) Is appropriately prescribed and considered safe and effective
for treating the medical condition of the insured.
2. The provisions of subsection 1 do not:
(a) Apply to coverage for any drug that is prescribed for a use
that is different from the use for which that drug has been approved for
marketing by the Food and Drug Administration;
(b) Prohibit:
(1) The organization from charging a deductible, copayment
or coinsurance for the provision of benefits for prescription drugs to
the insured or from establishing, by contract, limitations on the maximum
coverage for prescription drugs;
(2) A provider of health care from prescribing another drug
covered by the plan that is medically appropriate for the insured; or
(3) The substitution of another drug pursuant to NRS
639.23286 or 639.2583 to 639.2597 , inclusive; or
(c) Require any coverage for a drug after the term of the plan.
3. Any provision of a health care plan subject to the provisions
of this chapter that is delivered, issued for delivery or renewed on or
after October 1, 2001, which is in conflict with this section is void.
(Added to NRS by 2001, 866 ; A 2003, 2301 )
1. A health care plan issued by a managed care organization that
provides coverage for the treatment of colorectal cancer must provide
coverage for colorectal cancer screening in accordance with:
(a) The guidelines concerning colorectal cancer screening which are
published by the American Cancer Society; or
(b) Other guidelines or reports concerning colorectal cancer
screening which are published by nationally recognized professional
organizations and which include current or prevailing supporting
scientific data.
2. An evidence of coverage for a health care plan subject to the
provisions of this chapter that is delivered, issued for delivery or
renewed on or after October 1, 2003, has the legal effect of including
the coverage required by this section, and any provision of the evidence
of coverage that conflicts with the provisions of this section is void.
(Added to NRS by 2003, 1337 )
1. Each managed care organization shall provide coverage for
medically necessary emergency services provided at any hospital.
2. A managed care organization shall not require prior
authorization for medically necessary emergency services.
3. As used in this section, “medically necessary emergency
services” means health care services that are provided to an insured by a
provider of health care after the sudden onset of a medical condition
that manifests itself by symptoms of such sufficient severity that a
prudent person would believe that the absence of immediate medical
attention could result in:
(a) Serious jeopardy to the health of an insured;
(b) Serious jeopardy to the health of an unborn child;
(c) Serious impairment of a bodily function; or
(d) Serious dysfunction of any bodily organ or part.
4. A health care plan subject to the provisions of this section
that is delivered, issued for delivery or renewed on or after October 1,
1999, has the legal effect of including the coverage required by this
section, and any provision of the plan or the renewal which is in
conflict with this section is void.
(Added to NRS by 1997, 304; A 1999, 3097 )
1. A health care plan issued by a managed care organization must
provide coverage for medical treatment which a person insured under the
plan receives as part of a clinical trial or study if:
(a) The medical treatment is provided in a Phase I, Phase II, Phase
III or Phase IV study or clinical trial for the treatment of cancer or in
a Phase II, Phase III or Phase IV study or clinical trial for the
treatment of chronic fatigue syndrome;
(b) The clinical trial or study is approved by:
(1) An agency of the National Institutes of Health as set
forth in 42 U.S.C. § 281(b);
(2) A cooperative group;
(3) The Food and Drug Administration as an application for a
new investigational drug;
(4) The United States Department of Veterans Affairs; or
(5) The United States Department of Defense;
(c) In the case of:
(1) A Phase I clinical trial or study for the treatment of
cancer, the medical treatment is provided at a facility authorized to
conduct Phase I clinical trials or studies for the treatment of cancer; or
(2) A Phase II, Phase III or Phase IV study or clinical
trial for the treatment of cancer or chronic fatigue syndrome, the
medical treatment is provided by a provider of health care and the
facility and personnel for the clinical trial or study have the
experience and training to provide the treatment in a capable manner;
(d) There is no medical treatment available which is considered a
more appropriate alternative medical treatment than the medical treatment
provided in the clinical trial or study;
(e) There is a reasonable expectation based on clinical data that
the medical treatment provided in the clinical trial or study will be at
least as effective as any other medical treatment;
(f) The clinical trial or study is conducted in this State; and
(g) The insured has signed, before his participation in the
clinical trial or study, a statement of consent indicating that he has
been informed of, without limitation:
(1) The procedure to be undertaken;
(2) Alternative methods of treatment; and
(3) The risks associated with participation in the clinical
trial or study, including, without limitation, the general nature and
extent of such risks.
2. Except as otherwise provided in subsection 3, the coverage for
medical treatment required by this section is limited to:
(a) Coverage for any drug or device that is approved for sale by
the Food and Drug Administration without regard to whether the approved
drug or device has been approved for use in the medical treatment of the
insured.
(b) The cost of any reasonably necessary health care services that
are required as a result of the medical treatment provided in a Phase II,
Phase III or Phase IV clinical trial or study or as a result of any
complication arising out of the medical treatment provided in a Phase II,
Phase III or Phase IV clinical trial or study, to the extent that such
health care services would otherwise be covered under the health care
plan.
(c) The cost of any routine health care services that would
otherwise be covered under the health care plan for an insured in a Phase
I clinical trial or study.
(d) The initial consultation to determine whether the insured is
eligible to participate in the clinical trial or study.
(e) Health care services required for the clinically appropriate
monitoring of the insured during a Phase II, Phase III or Phase IV
clinical trial or study.
(f) Health care services which are required for the clinically
appropriate monitoring of the insured during a Phase I clinical trial or
study and which are not directly related to the clinical trial or study.
Ê Except as otherwise provided in NRS 695G.164 , the services provided pursuant to
paragraphs (b), (c), (e) and (f) must be covered only if the services are
provided by a provider with whom the managed care organization has
contracted for such services. If the managed care organization has not
contracted for the provision of such services, the managed care
organization shall pay the provider the rate of reimbursement that is
paid to other providers with whom the managed care organization has
contracted for similar services and the provider shall accept that rate
of reimbursement as payment in full.
3. Particular medical treatment described in subsection 2 and
provided to a person insured under the plan is not required to be covered
pursuant to this section if that particular medical treatment is provided
by the sponsor of the clinical trial or study free of charge to the
person insured under the plan.
4. The coverage for medical treatment required by this section
does not include:
(a) Any portion of the clinical trial or study that is customarily
paid for by a government or a biotechnical, pharmaceutical or medical
industry.
(b) Coverage for a drug or device described in paragraph (a) of
subsection 2 which is paid for by the manufacturer, distributor or
provider of the drug or device.
(c) Health care services that are specifically excluded from
coverage under the insured’s health care plan, regardless of whether such
services are provided under the clinical trial or study.
(d) Health care services that are customarily provided by the
sponsors of the clinical trial or study free of charge to the
participants in the trial or study.
(e) Extraneous expenses related to participation in the clinical
trial or study including, without limitation, travel, housing and other
expenses that a participant may incur.
(f) Any expenses incurred by a person who accompanies the insured
during the clinical trial or study.
(g) Any item or service that is provided solely to satisfy a need
or desire for data collection or analysis that is not directly related to
the clinical management of the insured.
(h) Any costs for the management of research relating to the
clinical trial or study.
5. A managed care organization that delivers or issues for
delivery a health care plan specified in subsection 1 may require copies
of the approval or certification issued pursuant to paragraph (b) of
subsection 1, the statement of consent signed by the insured, protocols
for the clinical trial or study and any other materials related to the
scope of the clinical trial or study relevant to the coverage of medical
treatment pursuant to this section.
6. A managed care organization that delivers or issues for
delivery a health care plan specified in subsection 1 shall:
(a) Include in the disclosure required pursuant to NRS 695C.193
notice to each person insured under
the plan of the availability of the benefits required by this section.
(b) Provide the coverage required by this section subject to the
same deductible, copayment, coinsurance and other such conditions for
coverage that are required under the plan.
7. A health care plan subject to the provisions of this chapter
that is delivered, issued for delivery or renewed on or after January 1,
2006, has the legal effect of including the coverage required by this
section, and any provision of the plan that conflicts with this section
is void.
8. A managed care organization that delivers or issues for
delivery a health care plan specified in subsection 1 is immune from
liability for:
(a) Any injury to an insured caused by:
(1) Any medical treatment provided to the insured in
connection with his participation in a clinical trial or study described
in this section; or
(2) An act or omission by a provider of health care who
provides medical treatment or supervises the provision of medical
treatment to the insured in connection with his participation in a
clinical trial or study described in this section.
(b) Any adverse or unanticipated outcome arising out of an
insured’s participation in a clinical trial or study described in this
section.
9. As used in this section:
(a) “Cooperative group” means a network of facilities that
collaborate on research projects and has established a peer review
program approved by the National Institutes of Health. The term includes:
(1) The Clinical Trials Cooperative Group Program; and
(2) The Community Clinical Oncology Program.
(b) “Facility authorized to conduct Phase I clinical trials or
studies for the treatment of cancer” means a facility or an affiliate of
a facility that:
(1) Has in place a Phase I program which permits only
selective participation in the program and which uses clear-cut criteria
to determine eligibility for participation in the program;
(2) Operates a protocol review and monitoring system which
conforms to the standards set forth in the Policies and Guidelines
Relating to the Cancer-Center Support Grant published by the Cancer
Centers Branch of the National Cancer Institute;
(3) Employs at least two researchers and at least one of
those researchers receives funding from a federal grant;
(4) Employs at least three clinical investigators who have
experience working in Phase I clinical trials or studies conducted at a
facility designated as a comprehensive cancer center by the National
Cancer Institute;
(5) Possesses specialized resources for use in Phase I
clinical trials or studies, including, without limitation, equipment that
facilitates research and analysis in proteomics, genomics and
pharmacokinetics;
(6) Is capable of gathering, maintaining and reporting
electronic data; and
(7) Is capable of responding to audits instituted by federal
and state agencies.
(c) “Provider of health care” means:
(1) A hospital; or
(2) A person licensed pursuant to chapter 630 , 631 or 633 of NRS.
(Added to NRS by 2003, 3533 ; A 2005, 2022 )
1. If a managed care organization contracts for the provision of
emergency medical services, outpatient services or inpatient services
with a hospital or other licensed health care facility that provides
acute care and is located in a city whose population is less than 60,000
or a county whose population is less than 100,000, the managed care
organization shall not:
(a) Prohibit an insured from receiving services covered by the
health care plan of the insured at that hospital or licensed health care
facility if the services are provided by a provider of health care with
whom the managed care organization has contracted for the provision of
the services;
(b) Refuse to provide coverage for services covered by the health
care plan of an insured that are provided to the insured at that hospital
or licensed health care facility if the services were provided by a
provider of health care with whom the managed care organization has
contracted for the provision of the services;
(c) Refuse to pay a provider of health care with whom the managed
care organization has contracted for the provision of services for
providing services to an insured at that hospital or licensed health care
facility if the services are covered by the health care plan of the
insured;
(d) Discourage a provider of health care with whom the managed care
organization has contracted for the provision of services from providing
services to an insured at that hospital or licensed health care facility
that are covered by the health care plan of the insured; or
(e) Offer or pay any type of material inducement, bonus or other
financial incentive to a provider of health care:
(1) To provide services to an insured that are covered by
the health care plan of the insured at another hospital or licensed
health care facility; or
(2) Not to provide services to an insured at that hospital
or licensed health care facility that are covered by the health care plan
of the insured.
2. Nothing in this section prohibits a managed care organization
from informing an insured that enhanced health care services are
available at a hospital or licensed health care facility other than the
hospital or licensed health care facility described in subsection 1 with
which the managed care organization contracts for the provision of
emergency medical services, outpatient services or inpatient services.
(Added to NRS by 1999, 1945 ; A 2001, 1998 )
QUALITY ASSURANCE PROGRAM
1. Each managed care organization shall establish a quality
assurance program designed to direct, evaluate and monitor the
effectiveness of health care services provided to its insureds. The
program must include, without limitation:
(a) A method for analyzing the outcomes of health care services;
(b) Peer review;
(c) A system to collect and maintain information related to the
health care services provided to insureds;
(d) Recommendations for remedial action; and
(e) Written guidelines that set forth the procedures for remedial
action when problems related to quality of care are identified.
2. Each managed care organization shall:
(a) Maintain a written description of the quality assurance program
established pursuant to subsection 1, including, without limitation, the
specific actions used by the managed care organization to promote
adequate quality of health care services provided to insureds and the
persons responsible for such actions;
(b) Provide information to each provider of health care whom it
employs or with whom it contracts to provide health care services to
insureds regarding the manner in which the quality assurance program
functions;
(c) Provide the necessary staff to implement the quality assurance
program and to evaluate the effectiveness of the program; and
(d) At least one time each year, review the continuity and
effectiveness of the quality assurance program, review any findings of
the quality improvement committee established pursuant to NRS 695G.190
and take any reasonable actions to
improve the program.
3. Each managed care organization is responsible for an activity
conducted pursuant to its quality assurance program, regardless of
whether the managed care organization or another entity performs the
activity.
(Added to NRS by 1997, 303)
1. As part of a quality assurance program established pursuant to
NRS 695G.180 , each managed care
organization shall create a quality improvement committee directed by a
physician who is licensed to practice medicine in the State of Nevada
pursuant to chapter 630 or 633 of NRS.
2. Each managed care organization shall:
(a) Establish written guidelines setting forth the procedure for
selecting the members of the committee;
(b) Select members pursuant to such guidelines; and
(c) Provide staff to assist the committee.
3. The committee shall:
(a) Select and review appropriate medical records of insureds and
other data related to the quality of health care provided to insureds by
providers of health care;
(b) Review the clinical processes used by providers of health care
in providing services;
(c) Identify any problems related to the quality of health care
provided to insureds; and
(d) Advise providers of health care regarding issues related to
quality of care.
(Added to NRS by 1997, 303; A 2003, 1182 )
SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS
1. Each managed care organization shall establish a system for
resolving complaints of an insured concerning:
(a) Payment or reimbursement for covered health care services;
(b) Availability, delivery or quality of covered health care
services, including, without limitation, an adverse determination made
pursuant to utilization review; or
(c) The terms and conditions of a health care plan.
Ê The system must be approved by the Commissioner in consultation with
the State Board of Health.
2. If an insured makes an oral complaint, a managed care
organization shall inform the insured that if he is not satisfied with
the resolution of the complaint, he must file the complaint in writing to
receive further review of the complaint.
3. Each managed care organization shall:
(a) Upon request, assign an employee of the managed care
organization to assist an insured or other person in filing a complaint
or appealing a decision of the review board;
(b) Authorize an insured who appeals a decision of the review board
to appear before the review board to present testimony at a hearing
concerning the appeal; and
(c) Authorize an insured to introduce any documentation into
evidence at a hearing of a review board and require an insured to provide
the documentation required by his health care plan to the review board
not later than 5 business days before a hearing of the review board.
4. The Commissioner or the State Board of Health may examine the
system for resolving complaints established pursuant to this section at
such times as either deems necessary or appropriate.
(Added to NRS by 1997, 305)
1. Except as otherwise provided in NRS 695G.300 , a system for resolving complaints created
pursuant to NRS 695G.200 must
include, without limitation, an initial investigation, a review of the
complaint by a review board and a procedure for appealing a determination
regarding the complaint. The majority of the members of the review board
must be insureds who receive health care services from the managed care
organization.
2. Except as otherwise provided in subsection 3, a review board
shall complete its review regarding a complaint or appeal and notify the
insured of its determination not later than 30 days after the complaint
or appeal is filed, unless the insured and the review board have agreed
to a longer period.
3. If a complaint involves an imminent and serious threat to the
health of the insured, the managed care organization shall inform the
insured immediately of his right to an expedited review of his complaint.
If an expedited review is required, the review board shall notify the
insured in writing of its determination within 72 hours after the
complaint is filed.
4. Notice provided to an insured by a review board regarding a
complaint must include, without limitation, an explanation of any further
rights of the insured regarding the complaint that are available under
his health care plan.
(Added to NRS by 1997, 306; A 2003, 783 )
1. Each managed care organization shall submit to the Commissioner
and the State Board of Health an annual report regarding its system for
resolving complaints established pursuant to NRS 695G.200 on a form prescribed by the Commissioner in
consultation with the State Board of Health which includes, without
limitation:
(a) A description of the procedures used for resolving complaints
of an insured;
(b) The total number of complaints and appeals handled through the
system for resolving complaints since the last report and a compilation
of the causes underlying the complaints filed;
(c) The current status of each complaint and appeal filed; and
(d) The average amount of time that was needed to resolve a
complaint and an appeal, if any.
2. Each managed care organization shall maintain records of
complaints filed with it which concern something other than health care
services and shall submit to the Commissioner a report summarizing such
complaints at such times and in such format as the Commissioner may
require.
(Added to NRS by 1997, 306)
1. After approval by the Commissioner, each managed care
organization shall provide a written notice to an insured, in clear and
comprehensible language that is understandable to an ordinary layperson,
explaining the right of the insured to file a written complaint and to
obtain an expedited review pursuant to NRS 695G.210 . Such a notice must be provided to an
insured:
(a) At the time he receives his certificate of coverage or evidence
of coverage;
(b) Any time that the managed care organization denies coverage of
a health care service or limits coverage of a health care service to an
insured; and
(c) Any other time deemed necessary by the Commissioner.
2. If a managed care organization denies coverage of a health care
service to an insured, including, without limitation, a health
maintenance organization that denies a claim related to a health care
plan pursuant to NRS 695C.185 , it
shall notify the insured in writing within 10 working days after it
denies coverage of the health care service of:
(a) The reason for denying coverage of the service;
(b) The criteria by which the managed care organization or insurer
determines whether to authorize or deny coverage of the health care
service;
(c) His right to:
(1) File a written complaint and the procedure for filing
such a complaint;
(2) Appeal a final adverse determination pursuant to NRS
695G.241 to 695G.310 , inclusive;
(3) Receive an expedited external review of a final adverse
determination if the managed care organization receives proof from the
insured’s provider of health care that failure to proceed in an expedited
manner may jeopardize the life or health of the insured, including
notification of the procedure for requesting the expedited external
review; and
(4) Receive assistance from any person, including an
attorney, for an external review of a final adverse determination; and
(d) The telephone number of the Office for Consumer Health
Assistance.
3. A written notice which is approved by the Commissioner shall be
deemed to be in clear and comprehensible language that is understandable
to an ordinary layperson.
(Added to NRS by 1997, 307; A 1999, 3097 ; 2003, 784 )
EXTERNAL REVIEW OF ADVERSE DETERMINATION
1. For the purposes of NRS 695G.200 to 695G.310 , inclusive, an adverse determination is
final if the insured has exhausted all procedures set forth in the health
care plan for reviewing the adverse determination within the managed care
organization.
2. An adverse determination shall be deemed final for the purpose
of submitting the adverse determination to an external review
organization for an external review:
(a) If an insured exhausts all procedures set forth in the health
care plan for reviewing the adverse determination within the managed care
organization and the managed care organization fails to render a decision
within the period required to render that decision set forth in the
health care plan; or
(b) If the managed care organization submits the adverse
determination to the external review organization without requiring the
insured to exhaust all procedures set forth in the health care plan for
reviewing the adverse determination within the managed care organization.
(Added to NRS by 2003, 780 )
1. If an insured or a physician of an insured receives notice of a
final adverse determination from a managed care organization concerning
the insured, and if the insured is required to pay $500 or more for the
health care services that are the subject of the final adverse
determination, the insured, the physician of the insured or an authorized
representative may, within 60 days after receiving notice of the final
adverse determination, submit a request to the managed care organization
for an external review of the final adverse determination.
2. Within 5 days after receiving a request pursuant to subsection
1, the managed care organization shall notify the insured, his authorized
representative or his physician, the agent who performed utilization
review for the managed care organization, if any, and the Office for
Consumer Health Assistance that the request has been filed with the
managed care organization.
3. As soon as practicable after receiving a notice pursuant to
subsection 2, the Office for Consumer Health Assistance shall assign an
external review organization from the list maintained pursuant to NRS
683A.371 . Each assignment made
pursuant to this subsection must be completed on a rotating basis.
4. Within 5 days after receiving notification from the Office for
Consumer Health Assistance specifying the external review organization
assigned pursuant to subsection 3, the managed care organization shall
provide to the external review organization all documents and materials
relating to the final adverse determination, including, without
limitation:
(a) Any medical records of the insured relating to the external
review;
(b) A copy of the provisions of the health care plan upon which the
final adverse determination was based;
(c) Any documents used by the managed care organization to make the
final adverse determination;
(d) The reasons for the final adverse determination; and
(e) Insofar as practicable, a list that specifies each provider of
health care who has provided health care to the insured and the medical
records of the provider of health care relating to the external review.
(Added to NRS by 2003, 780 )
1. Except as otherwise provided in NRS 695G.271 , upon receipt of a request for an external
review pursuant to NRS 695G.251 , the
external review organization shall, within 5 days after receiving the
request:
(a) Review the request and the documents and materials submitted
pursuant to NRS 695G.251 ; and
(b) Notify the insured, his physician and the managed care
organization if any additional information is required to conduct a
review of the final adverse determination.
2. Except as otherwise provided in NRS 695G.271 , the external review organization shall
approve, modify or reverse the final adverse determination within 15 days
after it receives the information required to make that determination
pursuant to this section. The external review organization shall submit a
copy of its determination, including the reasons therefor, to:
(a) The insured;
(b) The physician of the insured;
(c) The authorized representative of the insured, if any; and
(d) The managed care organization.
(Added to NRS by 2003, 781 )
1. A managed care organization shall approve or deny a request for
an external review of a final adverse determination in an expedited
manner not later than 72 hours after it receives proof from the insured’s
provider of health care that failure to proceed in an expedited manner
may jeopardize the life or health of the insured.
2. If a managed care organization approves a request for an
external review pursuant to subsection 1, the managed care organization
shall:
(a) In accordance with subsections 4 and 5, assign the request to
an external review organization not later than 1 working day after
approving the request; and
(b) At the time of assigning the request, provide to the external
review organization all documents and materials specified in subsection 4
of NRS 695G.251 .
3. An external review organization that is assigned to conduct an
external review pursuant to subsection 2 shall, if it accepts the
assignment:
(a) Complete its external review not later than 2 working days
after receiving the assignment, unless the insured and the managed care
organization agree to a longer period;
(b) Not later than 1 working day after completing its external
review, notify the insured, the physician of the insured, the authorized
representative of the insured, if any, and the managed care organization
by telephone of its determination; and
(c) Not later than 5 working days after completing its external
review, submit a written decision of its external review to the insured,
the physician of the insured, the authorized representative of the
insured, if any, and the managed care organization.
4. At least once each month, the Office for Consumer Health
Assistance shall designate at least 2 external review organizations to
conduct external reviews in an expedited manner pursuant to this section.
As soon as practicable after designating an external review organization
pursuant to this section, the Office for Consumer Health Assistance shall
notify each managed care organization of the designation.
5. As soon as practicable after assigning an external review
organization to conduct an external review pursuant to this section, the
managed care organization shall notify the Office for Consumer Health
Assistance of the assignment. Each assignment made by a managed care
organization pursuant to this section must be completed on a rotating
basis.
(Added to NRS by 2003, 781 )
The decision of an external review organization concerning a request for
an external review must be based on:
1. Documentary evidence, including any recommendation of the
physician of the insured submitted pursuant to NRS 695G.251 ;
2. Medical evidence, including, without limitation:
(a) Professional standards of safety and effectiveness for
diagnosis, care and treatment that are generally recognized in the United
States;
(b) Any report published in literature that is peer-reviewed;
(c) Evidence-based medicine, including, without limitation, reports
and guidelines that are published by professional organizations that are
recognized nationally and that include supporting scientific data; and
(d) An opinion of an independent physician who, as determined by
the external review organization, is an expert in the health specialty
that is the subject of the external review; and
3. The terms and conditions for benefits set forth in the evidence
of coverage issued to the insured by the managed care organization.
(Added to NRS by 2003, 782 )
1. If the determination of an external review organization
concerning an external review of a final adverse determination is in
favor of the insured, the determination is final, conclusive and binding
upon the managed care organization.
2. An external review organization or any clinical peer who
conducts or participates in an external review of a final adverse
determination for the external review organization is not liable in a
civil action for damages relating to a determination made by the external
review organization if the determination is made in good faith and
without gross negligence.
3. The cost of conducting an external review of a final adverse
determination pursuant to NRS 695G.241 to 695G.310 , inclusive, must be paid by the managed care
organization that made the final adverse determination.
(Added to NRS by 2003, 782 )
In lieu of resolving a complaint of an insured in
accordance with a system for resolving complaints established pursuant to
the provisions of NRS 695G.200 , a
managed care organization may:
1. Submit the complaint to an external review organization
pursuant to the provisions of NRS 695G.241 to 695G.310 , inclusive; or
2. If a federal law or regulation provides a procedure for
submitting the complaint for resolution that the Commissioner determines
is substantially similar to the procedure for submitting the complaint to
an external review organization pursuant to NRS 695G.241 to 695G.310 , inclusive, submit the complaint for
resolution in accordance with the federal law or regulation.
(Added to NRS by 2003, 782 )
On or before December
31 of each year, each managed care organization shall file a written
report with the Office for Consumer Health Assistance setting forth the
total number of:
1. Requests for external review that were received by the managed
care organization during the immediately preceding year; and
2. Final adverse determinations of the managed care organization
that were:
(a) Upheld during the immediately preceding year.
(b) Reversed during the immediately preceding year.
(Added to NRS by 2003, 783 ; A 2005, 1026 )
PROHIBITED ACTS
A managed care organization
shall not restrict or interfere with any communication between a provider
of health care and his patient regarding any information that the
provider of health care determines is relevant to the health care of the
patient.
(Added to NRS by 1997, 304)—(Substituted in revision for NRS
659G.240)
[Effective July 1, 2006.]
1. Except as otherwise provided in subsection 2, a managed care
organization shall not:
(a) Deny a claim under a health care plan solely because the claim
involves an injury sustained by an insured as a consequence of being
intoxicated or under the influence of a controlled substance.
(b) Cancel participation under a health care plan solely because an
insured has made a claim involving an injury sustained by the insured as
a consequence of being intoxicated or under the influence of a controlled
substance.
(c) Refuse participation under a health care plan to an eligible
applicant solely because the applicant has made a claim involving an
injury sustained by the applicant as a consequence of being intoxicated
or under the influence of a controlled substance.
2. The provisions of this section do not prohibit a managed care
organization from enforcing a provision included in a health care plan to:
(a) Deny a claim which involves an injury to which a contributing
cause was the insured’s commission of or attempt to commit a felony;
(b) Cancel participation under a health care plan solely because of
such a claim; or
(c) Refuse participation under a health care plan to an eligible
applicant solely because of such a claim.
(Added to NRS by 2005, 2347 , effective July 1, 2006)
A managed care organization shall not
terminate a contract with, demote, refuse to contract with or refuse to
compensate a provider of health care solely because the provider, in good
faith:
1. Advocates in private or in public on behalf of a patient;
2. Assists a patient in seeking reconsideration of a decision by
the managed care organization to deny coverage for a health care service;
or
3. Reports a violation of law to an appropriate authority.
(Added to NRS by 1997, 304)—(Substituted in revision for NRS
659G.250)
1. A managed care organization shall not offer or pay any type of
material inducement, bonus or other financial incentive to a provider of
health care to deny, reduce, withhold, limit or delay specific medically
necessary health care services to an insured.
2. Nothing in this section prohibits an arrangement for payment
between a managed care organization and a provider of health care that
uses capitation or other financial incentives, if the arrangement is
designed to provide an incentive to the provider of health care to use
health care services effectively and consistently in the best interest of
the health care of the insured.
(Added to NRS by 1997, 304)—(Substituted in revision for NRS
659G.260)
1. A managed care organization shall not contract with a provider
of health care to provide health care to an insured unless the managed
care organization uses the form prescribed by the Commissioner pursuant
to NRS 629.095 to obtain any
information related to the credentials of the provider of health care.
2. A contract between a managed care organization and a provider
of health care may be modified:
(a) At any time pursuant to a written agreement executed by both
parties.
(b) Except as otherwise provided in this paragraph, by the managed
care organization upon giving to the provider 30 days’ written notice of
the modification. If the provider fails to object in writing to the
modification within the 30-day period, the modification becomes effective
at the end of that period. If the provider objects in writing to the
modification within the 30-day period, the modification must not become
effective unless agreed to by both parties as described in paragraph (a).
3. If a managed care organization contracts with a provider of
health care to provide health care services pursuant to chapter 689A
, 689B , 689C
, 695A , 695B
or 695C of
NRS, the managed care organization shall:
(a) If requested by the provider of health care at the time the
contract is made, submit to the provider of health care the schedule of
payments applicable to the provider of health care; or
(b) If requested by the provider of health care at any other time,
submit to the provider of health care the schedule of payments specified
in paragraph (a) within 7 days after receiving the request.
4. As used in this section, “provider of health care” means a
provider of health care who is licensed pursuant to chapter 630 , 631 , 632 or 633 of NRS.
(Added to NRS by 2001, 2736 ; A 2003, 3371 )—(Substituted in revision for NRS
695G.270)
