[Rev. 11/21/2013 1:19:34 PM--2013]

CHAPTER 695G - MANAGED CARE

GENERAL PROVISIONS

NRS 695G.010        Definitions.

NRS 695G.012        “Adverse determination” defined.

NRS 695G.014        “Authorized representative” defined.

NRS 695G.015        “Benefits” defined.

NRS 695G.016        “Clinical peer” defined.

NRS 695G.017        “Covered person” defined.

NRS 695G.019        “Health benefit plan” defined.

NRS 695G.020        “Health care plan” defined.

NRS 695G.022        “Health care services” defined.

NRS 695G.024        “Health carrier” defined.

NRS 695G.026        “Independent review organization” defined.

NRS 695G.030        “Insured” defined.

NRS 695G.040        “Managed care” defined.

NRS 695G.050        “Managed care organization” defined.

NRS 695G.053        “Medical or scientific evidence” defined.

NRS 695G.055        “Medically necessary” defined.

NRS 695G.060        “Primary care physician” defined.

NRS 695G.070        “Provider of health care” defined.

NRS 695G.080        “Utilization review” defined.

NRS 695G.085        “Utilization review organization” defined.

NRS 695G.090        Applicability.

NRS 695G.095        Offering policy of health insurance for purposes of establishing health savings account.

NRS 695G.100        Documents treated as public record.

ADMINISTRATION OF MANAGED CARE ORGANIZATIONS

NRS 695G.110        Medical director must be physician licensed in this State.

NRS 695G.120        Utilization review: Written policies and procedures; subcontracting.

NRS 695G.125        Contracts with certain federally qualified health centers.

NRS 695G.130        Report regarding methods for reviewing quality of health care services: Requirements; availability for public inspection. [Effective through December 31, 2013.]

NRS 695G.130        Report regarding methods for reviewing quality of health care services: Requirements; availability for public inspection. [Effective January 1, 2014.]

NRS 695G.140        Responsibility for money in fiduciary relationship to insured.

COVERAGE BY MANAGED CARE ORGANIZATIONS

NRS 695G.150        Authorization of recommended and covered health care services required.

NRS 695G.160        Written criteria concerning coverage of health care services and standards for quality of health care services.

NRS 695G.163        Coverage for prescription drugs: Provision of notice and information regarding use of formulary.

NRS 695G.164        Required provision concerning coverage for continued medical treatment.

NRS 695G.1645      Required provision concerning coverage for autism spectrum disorders.

NRS 695G.166        Required provision concerning coverage for prescription drug previously approved for medical condition of insured.

NRS 695G.167        Required provision concerning coverage for orally administered chemotherapy.

NRS 695G.168        Required provision concerning coverage for screening for colorectal cancer.

NRS 695G.170        Required provision concerning coverage for medically necessary emergency services; prohibitions.

NRS 695G.171        Required provision concerning coverage for human papillomavirus vaccine. [Effective through December 31, 2013.]

NRS 695G.171        Required provision concerning coverage for human papillomavirus vaccine. [Effective January 1, 2014.]

NRS 695G.173        Required provision concerning coverage for treatment received as part of clinical trial or study. [Effective through December 31, 2013.]

NRS 695G.173        Required provision concerning coverage for treatment received as part of clinical trial or study. [Effective January 1, 2014.]

NRS 695G.175        Certain actions of managed care organization prohibited.

NRS 695G.177        Required provision concerning coverage for prostate cancer screening.

QUALITY ASSURANCE PROGRAM

NRS 695G.180        Quality assurance program: Requirements; written description; informing providers; necessary staff; review; responsibility for activities.

NRS 695G.190        Quality improvement committee: Administration; duties.

SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS

NRS 695G.200        Approval; requirements; assistance for persons filing complaints; examination. [Effective through December 31, 2013.]

NRS 695G.200        Approval; requirements; assistance for persons filing complaints; examination. [Effective January 1, 2014.]

NRS 695G.210        Review board; appeal; right to expedited review of complaint; notice to insured.

NRS 695G.220        Annual report; managed care organization to maintain records of complaints concerning something other than health care services. [Effective through December 31, 2013.]

NRS 695G.220        Annual report; managed care organization to maintain records of complaints concerning something other than health care services. [Effective January 1, 2014.]

NRS 695G.230        Written notice to insured explaining rights of insureds regarding decision to deny coverage; notice to insured when health carrier denies coverage of health care service.

EXTERNAL REVIEW OF ADVERSE DETERMINATION

NRS 695G.241        External review of adverse determination.

NRS 695G.243        Applicability.

NRS 695G.245        Written notice of right to request external review; form; contents.

NRS 695G.247        Requests for external review to be in writing; exception; form and content.

NRS 695G.251        Request for review; assignment of independent review organization; provision of documents relating to adverse determination to independent review organization.

NRS 695G.261        Review of documents by independent review organization; decision of independent review organization.

NRS 695G.271        Expedited approval or denial of request.

NRS 695G.275        Experimental or investigational health care service or treatment: Request for external review; request for expedited external review.

NRS 695G.280        Basis for decision of independent review organization.

NRS 695G.290        Decision in favor of covered person binding on health carrier; limitation of liability; cost for independent review organization.

NRS 695G.300        Submission of complaint of covered person to independent review organization.

NRS 695G.303        Independent review organization and health carrier to maintain written records; submission of report upon request.

NRS 695G.307        Health carrier to provide description of external review procedures; format; contents.

NRS 695G.310        Annual report; requirements.

PROHIBITED ACTS

NRS 695G.400        Managed care organization prohibited from interfering in or restricting certain communications.

NRS 695G.405        Managed care organization prohibited from denying coverage solely because insured was intoxicated or under the influence of controlled substance; exceptions.

NRS 695G.410        Certain actions taken against provider solely because provider advocates on behalf of patient, assists patient or reports violation of law prohibited.

NRS 695G.420        Offering or paying financial incentive to provider to deny, reduce, withhold, limit or delay medically necessary services prohibited.

NRS 695G.430        Contracts between managed care organization and provider of health care: Form for obtaining information on provider of health care; modification; schedule of fees.

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GENERAL PROVISIONS

      NRS 695G.010  Definitions.  As used in this chapter, unless the context otherwise requires, the words and terms defined in NRS 695G.012 to 695G.085, inclusive, have the meanings ascribed to them in those sections.

      (Added to NRS by 1997, 301; A 2003, 783; 2011, 3410)

      NRS 695G.012  “Adverse determination” defined.  “Adverse determination” means a determination by a health carrier or utilization review organization that an admission, availability of care, continued stay or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and the requested service or payment for the service is therefore denied, reduced or terminated.

      (Added to NRS by 2003, 779; A 2011, 3410)

      NRS 695G.014  “Authorized representative” defined.  “Authorized representative” means:

      1.  A person to whom a covered person has given express written consent to represent the covered person in an external review of an adverse determination conducted pursuant to NRS 695G.241 to 695G.310, inclusive;

      2.  A person authorized by law to provide substituted consent for a covered person; or

      3.  A family member of a covered person or the covered person’s treating provider only when the covered person is unable to provide consent.

      (Added to NRS by 2003, 779; A 2011, 3410)

      NRS 695G.015  “Benefits” defined.  “Benefits” means those health care services to which a covered person is entitled under the terms of a health benefit plan.

      (Added to NRS by 2011, 3398)

      NRS 695G.016  “Clinical peer” defined.  “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)

      NRS 695G.017  “Covered person” defined.  “Covered person” means a policyholder, subscriber, enrollee or other person participating in a health benefit plan.

      (Added to NRS by 2011, 3398)

      NRS 695G.019  “Health benefit plan” defined.  “Health benefit plan” means a policy, contract, certificate or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.

      (Added to NRS by 2011, 3398)

      NRS 695G.020  “Health care plan” defined.  “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)

      NRS 695G.022  “Health care services” defined.  “Health care services” means services for the diagnosis, prevention, treatment, care or relief of a health condition, illness, injury or disease.

      (Added to NRS by 2011, 3398)

      NRS 695G.024  “Health carrier” defined.  “Health carrier” means an entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the Commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services, including, without limitation, a sickness and accident health insurance company, a health maintenance organization, a nonprofit hospital and health service corporation or any other entity providing a plan of health insurance, health benefits or health care services.

      (Added to NRS by 2011, 3398)

      NRS 695G.026  “Independent review organization” defined.  “Independent review organization” means an entity that:

      1.  Conducts an independent external review of an adverse determination; and

      2.  Is certified by the Commissioner in accordance with NRS 683A.3715 and 683A.372.

      (Added to NRS by 2003, 779; A 2011, 3410)—(Substituted in revision for NRS 695G.018)

      NRS 695G.030  “Insured” defined.  “Insured” means a person who receives benefits under a health care plan.

      (Added to NRS by 1997, 301)

      NRS 695G.040  “Managed care” defined.  “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)

      NRS 695G.050  “Managed care organization” defined.  “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)

      NRS 695G.053  “Medical or scientific evidence” defined.  “Medical or scientific evidence” means evidence found in the following sources:

      1.  Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;

      2.  Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Library of Medicine of the National Institutes of Health for indexing in Index Medicus (MEDLINE) and Elsevier for indexing in Excerpta Medica (EMBASE);

      3.  Medical journals recognized by the Secretary of Health and Human Services pursuant to section 1861(t)(2) of the Social Security Act, 42 U.S.C. § 1395x;

      4.  The following standard reference compendia:

      (a) AHFS Drug Information published by the American Society of Health-System Pharmacists;

      (b) Drug Facts and Comparisons published by Wolter Kluwers Health;

      (c) Accepted Dental Therapeutics published by the American Dental Association; and

      (d) The United States Pharmacopoeia’s Drug Quality and Information Program;

      5.  Findings, studies or research conducted by or under the auspices of the Federal Government and nationally recognized federal research institutes, including, without limitation:

      (a) The Agency for Healthcare Research and Quality;

      (b) The National Institutes of Health;

      (c) The National Cancer Institute;

      (d) The National Academy of Sciences of the National Academies;

      (e) The Centers for Medicare and Medicaid Services;

      (f) The Food and Drug Administration; and

      (g) Any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health care services; or

      6.  Any other source of medical or scientific evidence that is comparable to the sources listed in subsections 1 to 5, inclusive.

      (Added to NRS by 2011, 3398)

      NRS 695G.055  “Medically necessary” defined.  “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 the existing state of health of the insured; and

      5.  The most clinically appropriate level of health care that may be safely provided to the insured.

      (Added to NRS by 2003, 779)

      NRS 695G.060  “Primary care physician” defined.  “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)

      NRS 695G.070  “Provider of health care” defined.  “Provider of health care” means:

      1.  A physician or other health care practitioner who is licensed or otherwise authorized in this State to furnish any health care service; and

      2.  An institution providing health care services or other setting in which health care services are provided, including, without limitation, a hospital, surgical center for ambulatory patients, facility for skilled nursing, residential facility for groups, laboratory and any other such licensed facility.

      (Added to NRS by 1997, 302; A 2011, 3411)

      NRS 695G.080  “Utilization review” defined.

      1.  “Utilization review” means the various methods that may be used to review the amount and appropriateness of the provision of a specific health care service.

      2.  The term does not include an external review of an adverse determination conducted pursuant to NRS 695G.241 to 695G.310, inclusive.

      (Added to NRS by 1997, 302; A 2003, 783; 2011, 3411)

      NRS 695G.085  “Utilization review organization” defined.  “Utilization review organization” means an entity designated by a health carrier to conduct utilization reviews.

      (Added to NRS by 2011, 3399)

      NRS 695G.090  Applicability.

      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.1645, 695G.167, 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; 2009, 1477; 2013, 2001)

      NRS 695G.095  Offering policy of health insurance for purposes of establishing health savings account.  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)

      NRS 695G.100  Documents treated as public record.  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

      NRS 695G.110  Medical director must be physician licensed in this State.  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)

      NRS 695G.120  Utilization review: Written policies and procedures; subcontracting.  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)

      NRS 695G.125  Contracts with certain federally qualified health centers.

      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)

      NRS 695G.130  Report regarding methods for reviewing quality of health care services: Requirements; availability for public inspection. [Effective through December 31, 2013.]

      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)

      NRS 695G.130  Report regarding methods for reviewing quality of health care services: Requirements; availability for public inspection. [Effective January 1, 2014.]

      1.  In addition to any other report which is required to be filed with the Commissioner, each managed care organization shall file with the Commissioner, 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, 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; 2013, 3650, effective January 1, 2014)

      NRS 695G.140  Responsibility for money in fiduciary relationship to insured.  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

      NRS 695G.150  Authorization of recommended and covered health care services required.  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 or her 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)

      NRS 695G.160  Written criteria concerning coverage of health care services and standards for quality of health care services.

      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)

      NRS 695G.163  Coverage for prescription drugs: Provision of notice and information regarding use of formulary.

      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)

      NRS 695G.164  Required provision concerning coverage for continued medical treatment.

      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 the provider of health care 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)

      NRS 695G.1645  Required provision concerning coverage for autism spectrum disorders.

      1.  A health care plan issued by a managed care organization for group coverage must provide coverage for screening for and diagnosis of autism spectrum disorders and for treatment of autism spectrum disorders to persons covered by the health care plan under the age of 18 or, if enrolled in high school, until the person reaches the age of 22.

      2.  A health care plan issued by a managed care organization for individual coverage must provide an option for coverage for screening for and diagnosis of autism spectrum disorders and for treatment of autism spectrum disorders to persons covered by the health care plan under the age of 18 or, if enrolled in high school, until the person reaches the age of 22.

      3.  Coverage provided under this section is subject to:

      (a) A maximum benefit of $36,000 per year for applied behavior analysis treatment; and

      (b) Copayment, deductible and coinsurance provisions and any other general exclusion or limitation of a health care plan to the same extent as other medical services or prescription drugs covered by the plan.

      4.  A managed care organization that offers or issues a health care plan which provides coverage for outpatient care shall not:

      (a) Require an insured to pay a higher deductible, copayment or coinsurance or require a longer waiting period for coverage for outpatient care related to autism spectrum disorders than is required for other outpatient care covered by the plan; or

      (b) Refuse to issue a health care plan or cancel a health care plan solely because the person applying for or covered by the plan uses or may use in the future any of the services listed in subsection 1.

      5.  Except as provided in subsections 1, 2 and 3, a managed care organization shall not limit the number of visits an insured may make to any person, entity or group for treatment of autism spectrum disorders.

      6.  Treatment of autism spectrum disorders must be identified in a treatment plan and may include medically necessary habilitative or rehabilitative care, prescription care, psychiatric care, psychological care, behavior therapy or therapeutic care that is:

      (a) Prescribed for a person diagnosed with an autism spectrum disorder by a licensed physician or licensed psychologist; and

      (b) Provided for a person diagnosed with an autism spectrum disorder by a licensed physician, licensed psychologist, licensed behavior analyst or other provider that is supervised by the licensed physician, psychologist or behavior analyst.

Ê A managed care organization may request a copy of and review a treatment plan created pursuant to this subsection.

      7.  An evidence of coverage subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2011, has the legal effect of including the coverage required by subsection 1, and any provision of the evidence of coverage or the renewal which is in conflict with subsection 1 or 3 is void.

      8.  Nothing in this section shall be construed as requiring a managed care organization to provide reimbursement to an early intervention agency or school for services delivered through early intervention or school services.

      9.  As used in this section:

      (a) “Applied behavior analysis” means the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including, without limitation, the use of direct observation, measurement and functional analysis of the relations between environment and behavior.

      (b) “Autism spectrum disorders” means a neurobiological medical condition including, without limitation, autistic disorder, Asperger’s Disorder and Pervasive Developmental Disorder Not Otherwise Specified.

      (c) “Behavioral therapy” means any interactive therapy derived from evidence-based research, including, without limitation, discrete trial training, early intensive behavioral intervention, intensive intervention programs, pivotal response training and verbal behavior provided by a licensed psychologist, licensed behavior analyst, licensed assistant behavior analyst or certified autism behavior interventionist.

      (d) “Certified autism behavior interventionist” means a person who is certified as an autism behavior interventionist by the Board of Psychological Examiners and who provides behavior therapy under the supervision of:

             (1) A licensed psychologist;

             (2) A licensed behavior analyst; or

             (3) A licensed assistant behavior analyst.

      (e) “Evidence-based research” means research that applies rigorous, systematic and objective procedures to obtain valid knowledge relevant to autism spectrum disorders.

      (f) “Habilitative or rehabilitative care” means counseling, guidance and professional services and treatment programs, including, without limitation, applied behavior analysis, that are necessary to develop, maintain and restore, to the maximum extent practicable, the functioning of a person.

      (g) “Licensed assistant behavior analyst” means a person who holds current certification or meets the standards to be certified as a board certified assistant behavior analyst issued by the Behavior Analyst Certification Board, Inc., or any successor in interest to that organization, who is licensed as an assistant behavior analyst by the Board of Psychological Examiners and who provides behavioral therapy under the supervision of a licensed behavior analyst or psychologist.

      (h) “Licensed behavior analyst” means a person who holds current certification or meets the standards to be certified as a board certified behavior analyst or a board certified assistant behavior analyst issued by the Behavior Analyst Certification Board, Inc., or any successor in interest to that organization and who is licensed as a behavior analyst by the Board of Psychological Examiners.

      (i) “Prescription care” means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications.

      (j) “Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.

      (k) “Psychological care” means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.

      (l) “Screening for autism spectrum disorders” means medically necessary assessments, evaluations or tests to screen and diagnose whether a person has an autism spectrum disorder.

      (m) “Therapeutic care” means services provided by licensed or certified speech pathologists, occupational therapists and physical therapists.

      (n) “Treatment plan” means a plan to treat an autism spectrum disorder that is prescribed by a licensed physician or licensed psychologist and may be developed pursuant to a comprehensive evaluation in coordination with a licensed behavior analyst.

      (Added to NRS by 2009, 1475)

      NRS 695G.166  Required provision concerning coverage for prescription drug previously approved for medical condition of insured.

      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)

      NRS 695G.167  Required provision concerning coverage for orally administered chemotherapy.

      1.  A managed care organization that offers or issues a health care plan which provides coverage for the treatment of cancer through the use of chemotherapy shall not:

      (a) Require a copayment, deductible or coinsurance amount for chemotherapy administered orally by means of a prescription drug in a combined amount that is more than $100 per prescription. The limitation on the amount of the deductible that may be required pursuant to this paragraph does not apply to a health benefit plan, as defined in NRS 687B.470, if the health benefit plan is a high deductible health plan, as defined in 26 U.S.C. § 223, and the amount of the annual deductible has not been satisfied.

      (b) Make the coverage subject to monetary limits that are less favorable for chemotherapy administered orally by means of a prescription drug than the monetary limits applicable to chemotherapy which is administered by injection or intravenously.

      (c) Decrease the monetary limits applicable to chemotherapy administered orally by means of a prescription drug or to chemotherapy which is administered by injection or intravenously to meet the requirements of this section.

      2.  An evidence of coverage for a health care plan subject to the provisions of this chapter which provides coverage for the treatment of cancer through the use of chemotherapy and that is delivered, issued for delivery or renewed on or after January 1, 2015, has the legal effect of providing that coverage subject to the requirements of this section, and any provision of the evidence of coverage or renewal which is in conflict with this section is void.

      3.  Nothing in this section shall be construed as requiring a managed care organization to provide coverage for the treatment of cancer through the use of chemotherapy administered by injection or intravenously or administered orally by means of a prescription drug.

      (Added to NRS by 2013, 2001; A 2013, 3660)

      NRS 695G.168  Required provision concerning coverage for screening for colorectal cancer.

      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)

      NRS 695G.170  Required provision concerning coverage for medically necessary emergency services; prohibitions.

      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)

      NRS 695G.171  Required provision concerning coverage for human papillomavirus vaccine. [Effective through December 31, 2013.]

      1.  A health care plan issued by a managed care organization must provide coverage for benefits payable for expenses incurred for administering the human papillomavirus vaccine to women and girls at such ages as recommended for vaccination by a competent authority, including, without limitation, the Centers for Disease Control and Prevention of the United States Department of Health and Human Services, the Food and Drug Administration or the manufacturer of the vaccine.

      2.  A health care plan must not require an insured to obtain prior authorization for any service provided pursuant to subsection 1.

      3.  An evidence of coverage for a health care plan subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after July 1, 2007, has the legal effect of including the coverage required by subsection 1, and any provision of the evidence of coverage or the renewal thereof which is in conflict with subsection 1 is void.

      4.  For the purposes of this section, “human papillomavirus vaccine” means the Quadrivalent Human Papillomavirus Recombinant Vaccine or its successor which is approved by the Food and Drug Administration for the prevention of human papillomavirus infection and cervical cancer.

      (Added to NRS by 2007, 3241)

      NRS 695G.171  Required provision concerning coverage for human papillomavirus vaccine. [Effective January 1, 2014.]

      1.  A health care plan issued by a managed care organization must provide coverage for benefits payable for expenses incurred for administering the human papillomavirus vaccine as recommended for vaccination by a competent authority, including, without limitation, the Centers for Disease Control and Prevention of the United States Department of Health and Human Services, the Food and Drug Administration or the manufacturer of the vaccine.

      2.  A health care plan must not require an insured to obtain prior authorization for any service provided pursuant to subsection 1.

      3.  An evidence of coverage for a health care plan subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after July 1, 2007, has the legal effect of including the coverage required by subsection 1, and any provision of the evidence of coverage or the renewal thereof which is in conflict with subsection 1 is void.

      4.  For the purposes of this section, “human papillomavirus vaccine” means the Quadrivalent Human Papillomavirus Recombinant Vaccine or its successor which is approved by the Food and Drug Administration for the prevention of human papillomavirus infection and cervical cancer.

      (Added to NRS by 2007, 3241; A 2013, 3651, effective January 1, 2014)

      NRS 695G.173  Required provision concerning coverage for treatment received as part of clinical trial or study. [Effective through December 31, 2013.]

      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 participating in the clinical trial or study, a statement of consent indicating that the insured 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 or her 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 or her 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)

      NRS 695G.173  Required provision concerning coverage for treatment received as part of clinical trial or study. [Effective January 1, 2014.]

      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 participating in the clinical trial or study, a statement of consent indicating that the insured 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 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 or her 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 or her 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; 2013, 3651, effective January 1, 2014)

      NRS 695G.175  Certain actions of managed care organization prohibited.

      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)

      NRS 695G.177  Required provision concerning coverage for prostate cancer screening.

      1.  A health care plan issued by a managed care organization that provides coverage for the treatment of prostate cancer must provide coverage for prostate cancer screening in accordance with:

      (a) The guidelines concerning prostate cancer screening which are published by the American Cancer Society; or

      (b) Other guidelines or reports concerning prostate cancer screening which are published by nationally recognized professional organizations and which include current or prevailing supporting scientific data.

      2.  A health care plan issued by a managed care organization that provides coverage for the treatment of prostate cancer must not require an insured to obtain prior authorization for any service provided pursuant to subsection 1.

      3.  Any evidence of coverage for a health care plan issued by a managed care organization that provides coverage for the treatment of prostate cancer which is delivered, issued for delivery or renewed on or after July 1, 2007, has the legal effect of including the coverage required by subsection 1, and any provision of the evidence of coverage or the renewal which is in conflict with subsection 1 is void.

      (Added to NRS by 2007, 3242)

QUALITY ASSURANCE PROGRAM

      NRS 695G.180  Quality assurance program: Requirements; written description; informing providers; necessary staff; review; responsibility for activities.

      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)

      NRS 695G.190  Quality improvement committee: Administration; duties.

      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

      NRS 695G.200  Approval; requirements; assistance for persons filing complaints; examination. [Effective through December 31, 2013.]

      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 the insured is not satisfied with the resolution of the complaint, the insured 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 the health care plan of the insured 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)

      NRS 695G.200  Approval; requirements; assistance for persons filing complaints; examination. [Effective January 1, 2014.]

      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 the insured is not satisfied with the resolution of the complaint, the insured 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 the health care plan of the insured to the review board not later than 5 business days before a hearing of the review board.

      4.  The Commissioner 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; A 2013, 3654, effective January 1, 2014)

      NRS 695G.210  Review board; appeal; right to expedited review of complaint; notice to insured.

      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 the right of the insured to an expedited review of the insured’s 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 the health care plan of the insured.

      (Added to NRS by 1997, 306; A 2003, 783)

      NRS 695G.220  Annual report; managed care organization to maintain records of complaints concerning something other than health care services. [Effective through December 31, 2013.]

      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)

      NRS 695G.220  Annual report; managed care organization to maintain records of complaints concerning something other than health care services. [Effective January 1, 2014.]

      1.  Each managed care organization shall submit to the Commissioner 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; A 2013, 3655, effective January 1, 2014)

      NRS 695G.230  Written notice to insured explaining rights of insureds regarding decision to deny coverage; notice to insured when health carrier denies coverage of health care service.

      1.  After approval by the Commissioner, each health carrier 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 the insured receives his or her certificate of coverage or evidence of coverage;

      (b) Any time that the health carrier 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 health carrier 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 health carrier or insurer determines whether to authorize or deny coverage of the health care service;

      (c) The right of the insured to:

             (1) File a written complaint and the procedure for filing such a complaint;

             (2) Appeal an adverse determination pursuant to NRS 695G.241 to 695G.310, inclusive;

             (3) Receive an expedited external review of an adverse determination if the health carrier 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 an 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; 2011, 3411)

EXTERNAL REVIEW OF ADVERSE DETERMINATION

      NRS 695G.241  External review of adverse determination.  Except as otherwise required for an expedited external review pursuant to NRS 695G.271 or 695G.275, for the purposes of NRS 695G.200 to 695G.310, inclusive, an adverse determination may be subject to an external review:

      1.  If a covered person exhausts all procedures set forth in the health care plan for reviewing the adverse determination within the health carrier and the health carrier fails to render a decision within the period required to render that decision set forth in the health care plan; or

      2.  If the health carrier allows the covered person to submit the adverse determination to the independent review organization without requiring the covered person to exhaust all procedures set forth in the health care plan for reviewing the adverse determination within the health carrier.

      (Added to NRS by 2003, 780; A 2011, 3412)

      NRS 695G.243  Applicability.

      1.  Except as otherwise provided in subsection 2, the provisions of NRS 695G.200 to 695G.310, inclusive, apply to all health carriers.

      2.  The provisions of subsection 1 do not apply to:

      (a) A policy or certificate that provides only coverage for:

             (1) A specified disease or accident;

             (2) Accidents;

             (3) Credit;

             (4) Dental;

             (5) Disability income;

             (6) Hospital indemnity;

             (7) Long-term care insurance;

             (8) Vision care; or

             (9) Any other limited supplemental benefit;

      (b) A Medicare supplement policy of insurance, as defined in regulations adopted by the Commissioner;

      (c) Coverage under a plan through Medicare, Medicaid or the Federal Employees Health Benefits Program, FEHBP, 5 U.S.C. §§ 8901 et seq.;

      (d) Any coverage issued under the Civilian Health and Medical Program of the Uniformed Services, CHAMPUS, 10 U.S.C. §§ 1071 et seq., and any coverage issued as supplemental to that coverage;

      (e) Any coverage issued as supplemental to liability insurance;

      (f) Workers’ compensation or similar insurance;

      (g) Automobile medical payment insurance; or

      (h) Any insurance under which benefits are payable with or without regard to fault, whether written on a group, blanket or individual basis.

      (Added to NRS by 2011, 3399)

      NRS 695G.245  Written notice of right to request external review; form; contents.

      1.  A health carrier shall notify the covered person in writing of the covered person’s right to request an external review to be conducted pursuant to NRS 695G.241 to 695G.310, inclusive, and include the appropriate statements and information set forth in subsection 2 at the same time the health carrier sends written notice of an adverse determination upon completion of the health carrier’s utilization review process set forth in NRS 683A.375 to 683A.379, inclusive, and the regulations adopted pursuant thereto.

      2.  As part of the written notice required pursuant to subsection 1, a health carrier shall include the following, or substantially equivalent, language:

 

We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested by submitting a request for external review to the Office for Consumer Health Assistance.

 

      3.  The Commissioner may prescribe by regulation the form and content of the notice required pursuant to this section.

      4.  The health carrier shall include in the notice required pursuant to subsection 1 a statement informing the covered person that:

      (a) If the covered person has a medical condition where the timeframe for completion of an expedited review of a grievance involving an adverse determination set forth in NRS 695G.200 to 695G.230, inclusive, would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, the covered person or the covered person’s authorized representative may, at the same time the covered person or the covered person’s authorized representative files a request for an expedited review of a grievance involving an adverse determination as set forth in NRS 695G.210, file a request for an expedited external review to be conducted pursuant to NRS 695G.271 and 695G.275 if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person’s treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated, and the independent review organization assigned to conduct the expedited external review will determine whether the covered person will be required to complete the expedited review of the grievance before conducting the expedited external review; and

      (b) The covered person or the covered person’s authorized representative may file a grievance under the health carrier’s internal grievance process as set forth in NRS 695G.200 to 695G.230, inclusive, but if the health carrier has not issued a written decision to the covered person or the covered person’s authorized representative within 30 days after the date on which the covered person or the covered person’s authorized representative filed the grievance with the health carrier and the covered person or the covered person’s authorized representative has not requested or agreed to a delay, the covered person or the covered person’s authorized representative may file a request for external review pursuant to NRS 695G.251 and shall be considered to have exhausted the health carrier’s internal grievance process.

      5.  In addition to the information required to be provided pursuant to subsection 1, the health carrier shall include a copy of the description of both the standard and expedited external review procedures the health carrier is required to provide pursuant to NRS 695G.307, highlighting the provisions in the external review procedures that give the covered person or the covered person’s authorized representative the opportunity to submit additional information and including any forms used to process an external review.

      6.  As part of any forms provided pursuant to subsection 3, the health carrier shall include an authorization form, or other document approved by the Commissioner that complies with the requirements of 45 C.F.R. § 164.508, by which the covered person, for purposes of conducting an external review, authorizes the health carrier and the covered person’s treating health care provider to disclose protected health information, including medical records, concerning the covered person that are pertinent to the external review.

      7.  As used in this section, “protected health information” has the meaning ascribed to it in 45 C.F.R. § 160.103.

      (Added to NRS by 2011, 3400)

      NRS 695G.247  Requests for external review to be in writing; exception; form and content.

      1.  Except for a request for an expedited external review as set forth in NRS 695G.271 or 695G.275, all requests for external review must be made in writing to the Office for Consumer Health Assistance.

      2.  The Commissioner may prescribe by regulation the form and content of requests for external review required to be submitted pursuant to this section.

      3.  A covered person or the covered person’s authorized representative may submit a request for an external review of an adverse determination.

      (Added to NRS by 2011, 3401)

      NRS 695G.251  Request for review; assignment of independent review organization; provision of documents relating to adverse determination to independent review organization.

      1.  If a covered person or a physician of a covered person receives notice of an adverse determination from a health carrier concerning the covered person, the covered person, the physician of the covered person or an authorized representative may, within 4 months after receiving notice of the adverse determination, submit a request to the Office for Consumer Health Assistance for an external review of the adverse determination.

      2.  Within 5 days after receiving a request pursuant to subsection 1, the Office for Consumer Health Assistance shall notify the covered person, the authorized representative or physician of the covered person, the agent who performed utilization review for the health carrier, if any, and the health carrier that the request has been filed with the Office for Consumer Health Assistance.

      3.  As soon as practicable after receiving a request pursuant to subsection 1, the Office for Consumer Health Assistance shall assign an independent review organization from the list maintained pursuant to NRS 683A.3715. 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 independent review organization assigned pursuant to subsection 3, the health carrier shall provide to the independent review organization all documents and materials relating to the 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 benefit plan upon which the adverse determination was based;

      (c) Any documents used by the health carrier to make the adverse determination;

      (d) The reasons for the adverse determination; and

      (e) Insofar as practicable, a list that specifies each provider of health care who has provided health care to the covered person and the medical records of the provider of health care relating to the external review.

      (Added to NRS by 2003, 780; A 2011, 3412)

      NRS 695G.261  Review of documents by independent review organization; decision of independent review organization.

      1.  Except as otherwise provided in NRS 695G.271 and 695G.275, upon receipt of a request for an external review pursuant to NRS 695G.251, the independent 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 covered person, the physician of the covered person and the health carrier if any additional information is required to conduct a review of the adverse determination. Such additional information must be provided within 5 days after receiving notice that the information is required to conduct a review of the adverse determination. The independent review organization shall forward to the health carrier, within 1 business day after receipt, any information received from a covered person or the physician of a covered person.

      2.  Except as otherwise provided in NRS 695G.271 and 695G.275, the independent review organization shall approve, modify or reverse the adverse determination within 15 days after it receives the information required to make that determination pursuant to this section. The independent review organization shall submit a copy of its determination, including the reasons therefor, to:

      (a) The covered person;

      (b) The physician of the covered person;

      (c) The authorized representative of the covered person, if any; and

      (d) The health carrier.

      (Added to NRS by 2003, 781; A 2011, 3413)

      NRS 695G.271  Expedited approval or denial of request.

      1.  The Office for Consumer Health Assistance shall approve or deny a request for an external review of an adverse determination in an expedited manner not later than 72 hours after it receives proof from the provider of health care of the covered person that:

      (a) The adverse determination concerns an admission, availability of care, continued stay or health care service for which the covered person received emergency services but has not been discharged from the facility providing the services or care; or

      (b) Failure to proceed in an expedited manner may jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function.

      2.  If the Office for Consumer Health Assistance approves a request for an external review pursuant to subsection 1, the Office for Consumer Health Assistance shall assign the request to an independent review organization not later than 1 working day after approving the request. Each assignment made by the Office for Consumer Health Assistance pursuant to this section must be completed on a rotating basis.

      3.  Within 24 hours after receiving notice of the Officer for Consumer Health Assistance assigning the request, the health carrier shall provide to the independent review organization all documents and materials specified in subsection 4 of NRS 695G.251.

      4.  An independent 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 48 hours after receiving the assignment, unless the covered person and the health carrier agree to a longer period;

      (b) Not later than 24 hours after completing its external review, notify the covered person, the physician of the covered person, the authorized representative, if any, and the health carrier by telephone of its determination; and

      (c) Not later than 48 hours after completing its external review, submit a written decision of its external review to the covered person, the physician of the covered person, the authorized representative, if any, and the health carrier.

      (Added to NRS by 2003, 781; A 2011, 3413)

      NRS 695G.275  Experimental or investigational health care service or treatment: Request for external review; request for expedited external review.

      1.  Within 4 months after receipt of a notice of an adverse determination pursuant to NRS 695G.245 that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational, a covered person or the covered person’s authorized representative may file a request for external review with the Office for Consumer Health Assistance pursuant to this section.

      2.  A covered person or the covered person’s authorized representative may make an oral request for an expedited external review of the adverse determination pursuant to NRS 695G.245 that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational if the covered person’s treating physician certifies, in writing, that the recommended or requested health care service or treatment that is the subject of the request would be significantly less effective if not promptly initiated.

      3.  Upon receipt of a request for an expedited external review pursuant to subsection 2, the Office for Consumer Health Assistance shall immediately notify the health carrier.

      4.  Immediately upon notice of a request for an expedited external review pursuant to subsection 2, the health carrier shall determine whether the request meets the requirements for review set forth in subsection 12. The health carrier shall immediately notify the Office for Consumer Health Assistance and the covered person and, if applicable, the covered person’s authorized representative, of its determination regarding eligibility.

      5.  The Commissioner may specify the form for the notice of initial determination pursuant to subsection 4 and any supporting information to be included in the notice.

      6.  The notice of initial determination required by subsection 4 must include a statement that a health carrier’s initial determination that a request which is ineligible for external review may be appealed to the Office for Consumer Health Assistance.

      7.  The Office for Consumer Health Assistance may determine that a request for an expedited external review is eligible for external review pursuant to subsection 12 and require that it be referred for expedited external review notwithstanding a health carrier’s initial determination that the request is ineligible.

      8.  In making a determination pursuant to subsection 7, the decision of the Office for Consumer Health Assistance must be made in accordance with the terms of the covered person’s health benefit plan and is subject to all applicable provisions of the external review process.

      9.  Upon receipt of the notice that the request for expedited external review meets the requirements for review, the Office for Consumer Health Assistance shall immediately assign an independent review organization to conduct the expedited external review from the list of approved independent review organizations compiled and maintained by the Commissioner pursuant to NRS 683A.3715 and notify the health carrier of the name of the assigned independent review organization.

      10.  Upon receipt of the notice pursuant to subsection 9, the health carrier or utilization review organization shall provide or transmit any documents and information considered in making the adverse determination to the assigned independent review organization electronically or by telephone or facsimile, or any other available expeditious method.

      11.  Except as otherwise provided in subsection 3, within 1 business day after receipt of a request for external review pursuant to subsection 1, the Office for Consumer Health Assistance shall notify the health carrier.

      12.  Within 5 business days after receipt of the notice sent pursuant to subsection 11, the health carrier shall conduct and complete a preliminary review of the request to determine whether:

      (a) The person is or was a covered person in the health benefit plan at the time the health care service or treatment was recommended or requested or, in the case of a retrospective review, was a covered person in the health benefit plan at the time the health care service or treatment was provided;

      (b) The recommended or requested health care service or treatment that is the subject of the adverse determination:

             (1) Would be a covered benefit under the covered person’s health benefit plan but for the health carrier’s determination that the health care service or treatment is experimental or investigational for a particular medical condition; and

             (2) Is not explicitly listed as an excluded benefit under the covered person’s health benefit plan;

      (c) The covered person’s treating physician has certified that one of the following situations is applicable:

             (1) Standard health care services or treatments have not been effective in improving the condition of the covered person;

             (2) Standard health care services or treatments are not medically appropriate for the covered person; or

             (3) There is no available standard health care service or treatment covered by the health carrier that is more beneficial than the recommended or requested health care service or treatment described in paragraph (d);

      (d) The covered person’s treating physician:

             (1) Has recommended a health care service or treatment that the physician certifies, in writing, is likely to be more beneficial to the covered person, in the physician’s opinion, than any available standard health care services or treatments; or

             (2) Who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat the covered person’s condition, has certified in writing that scientifically valid studies using accepted protocols demonstrate that the health care service or treatment requested by the covered person that is the subject of the adverse determination is likely to be more beneficial to the covered person than any available standard health care services or treatments;

      (e) The covered person has exhausted the health carrier’s internal grievance process as set forth in NRS 695G.200 to 695G.230, inclusive, unless the covered person is not required to exhaust the health carrier’s internal grievance process; and

      (f) The covered person has provided all the information and forms required by the Office for Consumer Health Assistance to process an external review, including the release form provided pursuant to subsection 6 of NRS 695G.245.

      13.  Within 1 business day after completion of the preliminary review, the health carrier shall notify the Office for Consumer Health Assistance and the covered person, and, if applicable, the covered person’s authorized representative, in writing, whether the request is:

      (a) Complete;

      (b) Eligible for external review;

      (c) Not complete, in which case the health carrier shall include in the notice the information or materials that are needed to make the request complete; or

      (d) Not eligible for external review, in which case the health carrier shall include in the notice the reasons for its ineligibility.

      14.  The Commissioner may specify the form for the notice of initial determination pursuant to subsection 13 and any supporting information to be included in the notice.

      15.  The notice of initial determination must include a statement informing the covered person and, if applicable, the covered person’s authorized representative that a health carrier’s initial determination that a request which is ineligible for external review may be appealed to the Office for Consumer Health Assistance.

      16.  The Office for Consumer Health Assistance may determine that a request is eligible for external review pursuant to subsection 12 and require that it be referred for external review notwithstanding a health carrier’s initial determination that the request is ineligible.

      17.  In making a determination pursuant to subsection 16, the decision of the Office for Consumer Health Assistance must be made in accordance with the terms of the covered person’s health benefit plan and is subject to all applicable provisions of the external review process.

      18.  When a health carrier determines that a request is eligible for external review pursuant to subsection 12, the health carrier shall notify the Office for Consumer Health Assistance and the covered person and, if applicable, the covered person’s authorized representative.

      19.  Within 1 business day after receipt of the notice from the health carrier that the external review request is eligible for external review pursuant to subsection 18, the Office for Consumer Health Assistance shall:

      (a) Assign an independent review organization from the list of approved independent review organizations compiled and maintained by the Commissioner pursuant to NRS 683A.3715 to conduct the external review;

      (b) Notify the health carrier of the name of the assigned independent review organization; and

      (c) Notify in writing the covered person and, if applicable, the covered person’s authorized representative that the request is eligible for external review and provide the name of the assigned independent review organization.

      20.  The Office for Consumer Health Assistance shall include in the notice provided to the covered person and, if applicable, the covered person’s authorized representative pursuant to subsection 19 a statement that the covered person or the covered person’s authorized representative may submit in writing to the assigned independent review organization within 5 business days after receipt of the notice provided pursuant to subsection 19 additional information that the independent review organization shall consider when conducting the external review. The independent review organization may accept and consider additional information submitted after the 5 business days have elapsed.

      21.  Within 1 business day after receipt of the notice of assignment to conduct the external review pursuant to subsection 19, the assigned independent review organization shall:

      (a) Select one or more clinical reviewers to conduct the external review, as it determines is appropriate; and

      (b) Based on the opinion of the clinical reviewer, or opinions if more than one clinical reviewer has been selected to conduct the external review, make a decision to uphold or reverse the adverse determination.

      22.  In selecting clinical reviewers pursuant to paragraph (a) of subsection 21, the assigned independent review organization shall select health care professionals who meet the minimum qualifications described in NRS 683A.372 and through clinical experience in the past 3 years, are experts in the treatment of the covered person’s condition and knowledgeable about the recommended or requested health care service or treatment.

      23.  The covered person, the covered person’s authorized representative, if applicable, and the health carrier may not choose or control the choice of the health care professionals to be selected to conduct the external review.

      24.  In accordance with subsections 37 to 41, inclusive, each clinical reviewer shall provide a written opinion to the assigned independent review organization regarding whether the recommended or requested health care service or treatment should be covered.

      25.  In reaching an opinion, clinical reviewers are not bound by any decisions or conclusions reached during the health carrier’s utilization review process as set forth in NRS 683A.375 to 683A.379, inclusive, or the health carrier’s internal grievance process as set forth in NRS 695G.200 to 695G.230, inclusive.

      26.  Within 5 business days after receipt of the notice pursuant to subsection 19, the health carrier or utilization review organization shall provide to the assigned independent review organization any documents and information considered in making the adverse determination.

      27.  Except as otherwise provided in subsection 28, failure by the health carrier or utilization review organization to provide the documents and information within the time specified in subsection 26 must not delay the conduct of the external review.

      28.  If the health carrier or utilization review organization fails to provide the documents and information within the time specified in subsection 26, the assigned independent review organization may terminate the external review and make a decision to reverse the adverse determination.

      29.  If the independent review organization elects to terminate the external review and reverse the adverse determination pursuant to subsection 28, the independent review organization shall immediately notify the covered person, the covered person’s authorized representative, if applicable, the health carrier and the Office for Consumer Health Assistance.

      30.  Each clinical reviewer selected pursuant to subsection 21 shall review all the information and documents received pursuant to subsections 20 and 26.

      31.  The assigned independent review organization shall forward any information submitted by the covered person or the covered person’s authorized representative pursuant to subsection 20 to the health carrier within 1 business day after receipt of the information.

      32.  Upon receipt of the information required to be forwarded pursuant to subsection 31, the health carrier may reconsider the adverse determination that is the subject of the external review.

      33.  Reconsideration by the health carrier of its adverse determination pursuant to subsection 32 must not delay or terminate the external review.

      34.  Except as otherwise provided in subsection 28, the external review may only be terminated before completion if the health carrier decides, upon completion of its reconsideration, to reverse its adverse determination and provide coverage or payment for the recommended or requested health care service or treatment that is the subject of the adverse determination.

      35.  If the health carrier reverses its adverse determination pursuant to subsection 28, the health carrier shall immediately notify the covered person, the covered person’s authorized representative, if applicable, the assigned independent review organization and the Office for Consumer Health Assistance in writing of its decision.

      36.  The assigned independent review organization shall terminate the external review upon receipt of the notice from the health carrier pursuant to subsection 35.

      37.  Except as otherwise provided in subsection 39, within 20 days after being selected in accordance with subsection 21 to conduct the external review, each clinical reviewer shall provide an opinion to the assigned independent review organization pursuant to subsection 41 regarding whether the recommended or requested health care service or treatment should be covered.

      38.  Except for an opinion provided pursuant to subsection 39, each clinical reviewer’s opinion must be in writing and include the following:

      (a) A description of the covered person’s medical condition;

      (b) A description of the indicators relevant to determine if there is sufficient evidence to demonstrate that the recommended or requested health care service or treatment is more likely to be beneficial to the covered person than any available standard health care services or treatments and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments;

      (c) A description and analysis of any medical or scientific evidence considered in reaching the opinion;

      (d) A description and analysis of any evidence-based standards used as a basis for the opinion; and

      (e) Information concerning whether the reviewer’s rationale for the opinion is based on the provisions of subsection 41.

      39.  For an expedited external review, each clinical reviewer shall provide an opinion orally or in writing to the assigned independent review organization as expeditiously as the covered person’s medical condition or circumstances requires, but in no event not more than 5 calendar days after being selected in accordance with subsection 21.

      40.  If the opinion provided pursuant to subsection 39 was not in writing, within 48 hours after providing that notice, the clinical reviewer shall provide written confirmation of the opinion to the assigned independent review organization and include the information required pursuant to subsection 38.

      41.  In addition to the documents and information provided pursuant to subsections 10 and 26, each clinical reviewer, to the extent the information or documents are available and the reviewer considers them appropriate, shall consider the following in reaching an opinion:

      (a) The covered person’s medical records;

      (b) The attending health care professional’s recommendation;

      (c) Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, covered person, the covered person’s authorized representative or the covered person’s treating provider;

      (d) The terms of coverage under the covered person’s health benefit plan with the health carrier to ensure that, but for the health carrier’s determination that the recommended or requested health care service or treatment that is the subject of the opinion is experimental or investigational, the reviewer’s opinion is not contrary to the terms of coverage under the health benefit plan; and

      (e) Whether:

             (1) The recommended or requested health care service or treatment has been approved by the Food and Drug Administration, if applicable, for the condition; or

             (2) Medical or scientific evidence or evidence-based standards demonstrate that the expected benefits of the recommended or requested health care service or treatment is more likely to be beneficial to the covered person than any available standard health care services or treatments and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments.

      42.  Except as otherwise provided in subsection 43, within 20 days after receipt of the opinion of each clinical reviewer pursuant to subsection 41, the assigned independent review organization, in accordance with subsection 45 or 46, shall make a decision and provide written notice of the decision to the covered person, the covered person’s authorized representative, if applicable, the health carrier and the Office for Consumer Health Assistance and include the information required pursuant to subsection 50.

      43.  For an expedited external review, within 48 hours after receipt of the opinion of each clinical reviewer pursuant to subsection 41, the assigned independent review organization, in accordance with subsection 45 or 46, shall make a decision and provide notice of the decision orally or in writing to the covered person, the covered person’s authorized representative, if applicable, the health carrier and the Office for Consumer Health Assistance.

      44.  If the notice provided pursuant to subsection 43 was not in writing, within 48 hours after providing that notice, the assigned independent review organization shall provide written confirmation of the decision to the covered person, the covered person’s authorized representative, if applicable, the health carrier and the Office for Consumer Health Assistance and include the information required pursuant to subsection 50.

      45.  If a majority of the clinical reviewers recommend that the recommended or requested health care service or treatment should be covered, the independent review organization shall make a decision to reverse the health carrier’s adverse determination.

      46.  If a majority of the clinical reviewers recommend that the recommended or requested health care service or treatment should not be covered, the independent review organization shall make a decision to uphold the health carrier’s adverse determination.

      47.  If the clinical reviewers are evenly split as to whether the recommended or requested health care service or treatment should be covered, the independent review organization shall obtain the opinion of an additional clinical reviewer in order for the independent review organization to make a decision based on the opinions of a majority of the clinical reviewers pursuant to subsection 45 or 46.

      48.  The additional clinical reviewer selected pursuant to subsection 47 shall use the same information to reach an opinion as the clinical reviewers who have already submitted their opinions pursuant to subsection 41.

      49.  The selection of an additional clinical reviewer pursuant to subsection 47 must not extend the time within which the assigned independent review organization is required to make a decision based on the opinions of the clinical reviewers pursuant to subsection 42.

      50.  The independent review organization shall include in the notice provided pursuant to subsection 42 or 44:

      (a) A general description of the reason for the request for external review;

      (b) The written opinion of each clinical reviewer, including the recommendation of each clinical reviewer as to whether the recommended or requested health care service or treatment should be covered and the rationale for the reviewer’s recommendation;

      (c) The date the independent review organization was assigned by the Office for Consumer Health Assistance to conduct the external review;

      (d) The date on which the external review was conducted;

      (e) The date of the decision;

      (f) The principal reason or reasons for the decision; and

      (g) The rationale for the decision.

      51.  Upon receipt of a notice of a decision pursuant to subsection 42 or 44 reversing the adverse determination, the health carrier shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination.

      52.  The assignment by the Office for Consumer Health Assistance of an approved independent review organization to conduct an external review in accordance with this section must be done on a random basis among those approved independent review organizations qualified to conduct the particular external review based on the nature of the health care service or treatment that is the subject of the adverse determination and other circumstances, including concerns regarding conflicts of interest pursuant to subsection 4 of NRS 683A.372.

      53.  As used in this section:

      (a) “Best evidence” means evidence based on:

             (1) Randomized clinical trials;

             (2) If randomized clinical trials are not available, cohort studies or case-control studies;

             (3) If the methods described in subparagraphs (1) and (2) are not available, case series; or

             (4) If the methods described in subparagraphs (1), (2) and (3) are not available, expert opinion.

      (b) “Evidence-based standard” means the conscientious, explicit and judicious use of the current best evidence based on the overall systematic review of research in making decisions about the care of an individual patient.

      (c) “Randomized clinical trial” means a controlled, prospective study of patients who have been randomized into an experimental group and a control group at the beginning of the study with only the experimental group of patients receiving a specific intervention, which includes study of the groups for variables and anticipated outcomes over time.

      (Added to NRS by 2011, 3401)

      NRS 695G.280  Basis for decision of independent review organization.  The decision of an independent 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 or scientific 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 independent review organization, is an expert in the health specialty that is the subject of the independent review; and

      3.  The terms and conditions for benefits set forth in the evidence of coverage issued to the insured by the health carrier.

      (Added to NRS by 2003, 782; A 2011, 3414)

      NRS 695G.290  Decision in favor of covered person binding on health carrier; limitation of liability; cost for independent review organization.

      1.  If the determination of an independent review organization concerning an external review of an adverse determination is in favor of the covered person, the determination is final, conclusive and binding upon the health carrier.

      2.  An independent review organization or any clinical peer who conducts or participates in an external review of an adverse determination for the independent review organization is not liable in a civil action for damages relating to a determination made by the independent review organization if the determination is made in good faith and without gross negligence.

      3.  The cost of conducting an external review of an adverse determination pursuant to NRS 695G.241 to 695G.310, inclusive, must be paid by the health carrier that made the adverse determination.

      (Added to NRS by 2003, 782; A 2011, 3415)

      NRS 695G.300  Submission of complaint of covered person to independent review organization.  In lieu of resolving a complaint of a covered person in accordance with a system for resolving complaints established pursuant to the provisions of NRS 695G.200, a health carrier may:

      1.  Submit the complaint to an independent 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 independent 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; A 2011, 3415)

      NRS 695G.303  Independent review organization and health carrier to maintain written records; submission of report upon request.

      1.  An independent review organization assigned pursuant to NRS 695G.251, 695G.271 or 695G.275 to conduct an external review shall maintain written records, aggregated for each state and for each health carrier, on all requests for which it conducted an external review during a calendar year and, upon request, submit a report to the Office for Consumer Health Assistance in a format specified by the Commissioner.

      2.  The report must include, aggregated for each state and for each health carrier:

      (a) The total number of requests for external review;

      (b) The number of requests for external review resolved and, of those resolved, the number upholding the adverse determination and the number reversing the adverse determination;

      (c) The average length of time for resolution;

      (d) A summary of the types of coverages or cases for which an external review was sought;

      (e) The number of external reviews that were terminated as the result of a reconsideration by the health carrier of its adverse determination after receipt of additional information from the covered person or the covered person’s authorized representative pursuant to subsection 4 of NRS 695G.251 and subsection 32 of NRS 695G.275; and

      (f) Any other information the Office for Consumer Health Assistance may request or require.

      3.  An independent review organization shall retain the written records required pursuant to this section for at least 3 years.

      4.  Each health carrier shall maintain written records, aggregated for each state and for each type of health benefit plan offered by the health carrier, on all requests for external review for which the health carrier receives notice from the Office for Consumer Health Assistance and, upon request, submit a report to the Office for Consumer Health Assistance in a format specified by the Commissioner.

      5.  The report must include, aggregated for each state and for each type of health benefit plan:

      (a) The total number of requests for external review;

      (b) Of the total number of requests for external review, the number of requests determined to be eligible for external review; and

      (c) Any other information the Office for Consumer Health Assistance may request or require.

      6.  A health carrier shall retain the written records required pursuant to this section for at least 3 years.

      (Added to NRS by 2011, 3409)

      NRS 695G.307  Health carrier to provide description of external review procedures; format; contents.

      1.  A health carrier shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage or other evidence of coverage it provides to covered persons.

      2.  The description required by subsection 1 must be in a format prescribed by the Commissioner.

      3.  The description required by subsection 1 must include a statement that informs the covered person of the right of the covered person to file a request for an external review of an adverse determination with the Office for Consumer Health Assistance. The statement may explain that external review is available when the adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care or effectiveness. The statement must include the telephone number and address of the Office for Consumer Health Assistance.

      4.  In addition to the requirements of subsection 3, the statement must inform the covered person that, when filing a request for an external review, the covered person will be required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.

      (Added to NRS by 2011, 3409)

      NRS 695G.310  Annual report; requirements.  On or before December 31 of each year, each health carrier shall file a written report with the Office for Consumer Health Assistance setting forth the total number of:

      1.  Requests for an external review of an adverse decision made by the health carrier which were granted by the Office for Consumer Health Assistance during the immediately preceding year; and

      2.  Adverse determinations of the health carrier 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; 2011, 3415)

PROHIBITED ACTS

      NRS 695G.400  Managed care organization prohibited from interfering in or restricting certain communications.  A managed care organization shall not restrict or interfere with any communication between a provider of health care and a patient of the provider of health care 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 695G.240)

      NRS 695G.405  Managed care organization prohibited from denying coverage solely because insured was intoxicated or under the influence of controlled substance; exceptions.

      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 subsection 1 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.

      3.  The provisions of this section do not apply to a managed care organization under a health care plan that provides coverage for long-term care or disability income.

      (Added to NRS by 2005, 2347; A 2007, 87)

      NRS 695G.410  Certain actions taken against provider solely because provider advocates on behalf of patient, assists patient or reports violation of law prohibited.  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 695G.250)

      NRS 695G.420  Offering or paying financial incentive to provider to deny, reduce, withhold, limit or delay medically necessary services prohibited.

      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 695G.260)

      NRS 695G.430  Contracts between managed care organization and provider of health care: Form for obtaining information on provider of health care; modification; schedule of fees.

      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 45 days’ written notice of the modification of the managed care organization’s schedule of payments, including any changes to the fee schedule applicable to the provider’s practice. If the provider fails to object in writing to the modification within the 45-day period, the modification becomes effective at the end of that period. If the provider objects in writing to the modification within the 45-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, including any changes to the fee schedule applicable to the provider’s practice, 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; 2011, 2536)—(Substituted in revision for NRS 695G.270)