NAC: CHAPTER 439B - RESTRAINING COSTS OF HEALTH CARE

[Rev. 6/7/2026 11:01:38 AM]

CHAPTER 439B - RESTRAINING COSTS OF HEALTH CARE

[NAC-439B Revised Date: 4-26]

GENERAL PROVISIONS

439B.010 Definitions.

439B.110 “Hospital fiscal year” defined.

439B.130 “Inpatient” defined.

439B.140 “Inpatient billed charges” defined.

439B.150 “Inpatient net revenue” defined.

439B.180 “Net revenue” defined.

439B.185 “Operating budget” defined.

FINANCIAL PRACTICES OF HOSPITALS

439B.220 Submission of quarterly reports.

439B.230 Submission of annual financial reports.

439B.240 Certification of financial reports; penalty for failure to submit information; request for extension of time.

439B.250 Submission of copy of audit.

439B.260 Independent audits; penalty for failure to cooperate.

MAJOR HOSPITALS

439B.325 Major hospital to provide disclosure to patient who does not have medical insurance; effect of discount on prior arrangement to pay; circumstances entitling hospital to recover discount.

439B.330 Determination of reasonableness of arrangement for payment; hospital to provide written notice of terms of arrangement and respective rights and obligations to patient; adjustment of monthly payments.

439B.335 Initial payment from patient upon admittance to hospital.

439B.340 Determination of annual rate of interest on unpaid balance of total billed charge; effect of delinquent account; sale, assignment or transfer of right to balance due on account.

CARE OF INDIGENT PATIENTS

General Requirements

439B.390 Applicability of certain provisions of NRS and NAC.

439B.410 Submission of copy of Medicare Cost Report and estimate of inpatient net revenue.

439B.420 Determination of minimum obligation.

439B.430 Reports on actual and estimated minimum obligation; notification to board of county commissioners.

439B.435 Delivery to hospitals of reports on indigent patients treated.

Appeal of Determination of Indigent Status

439B.441 Applicability.

439B.442 Exhaustion of administrative procedures.

439B.443 Filing and contents of appeal; submission of additional material upon request.

439B.444 Determination to hold hearing or to issue decision denying appeal without hearing.

439B.446 Scheduling and notice of hearing.

439B.447 Presentation of evidence at hearing.

439B.448 Issuance of decision after hearing.

439B.449 Contents of decision issued after hearing; effect of decision issued without or after hearing.

PROHIBITED CONTRACTS AND TRANSACTIONS

439B.455 Disclosure required of financial interest in facility or service to which patient referred.

439B.470 Procedure to determine whether prohibited contract between hospital and practitioner exists.

439B.480 Contracts and agreements which must be listed and submitted to Department.

439B.490 Preliminary procedure to determine whether prohibited transaction between hospital and related entity has occurred.

439B.500 Determination by Director of whether prohibited transaction between hospital and related entity has occurred.

439B.510 Reasonable cause to believe that prohibited transaction between hospital and related entity has occurred.

439B.520 Hearing required before imposition of penalty.

REFERRALS BY PRACTITIONERS

439B.5205 Definitions.

439B.5207 “Commercial establishment” defined.

439B.530 “Financial interest” defined.

439B.5304 “Medical laboratory” defined.

439B.5306 “One parcel of land” defined.

439B.540 “Refer” defined.

439B.5402 Prohibited referral of patients by agent, employee or independent contractor of practitioner.

439B.5404 Authorized referrals.

439B.5406 Authorized referrals to facilities in which practitioner has financial interest.

439B.5408 Investigation of possible prohibited referral by practitioner; determination by Director after investigation.

EDUCATIONAL PROGRAM TO PROMOTE WELLNESS, PHYSICAL FITNESS AND PREVENTION OF DISEASE AND ACCIDENTS

439B.550 Development and implementation of program.

439B.555 Description of program: Submission to Director; contents.

439B.560 Description of program: Accompanying statement.

439B.565 Notification by Director of decision regarding program; opportunity to make corrections.

PETITION FOR DECLARATORY ORDER OR ADVISORY OPINION

439B.600 Applicability.

439B.610 Contents of petition.

439B.620 Powers of Director: Designation of person to issue declaratory order or advisory opinion; consolidation of petitions for advisory opinions.

439B.630 Issuance of declaratory order or advisory opinion: Time for issuance; tolling of time for issuance; consolidated petitions.

439B.640 Copy of declaratory order or advisory opinion to be mailed to petitioner and made available to public.

REPORTING OF CERTAIN INFORMATION RELATING TO PRESCRIPTION DRUGS

439B.650 Authority to make available on Internet website forms for manufacturer, wholesaler, pharmacy benefit manager and pharmaceutical sales representative to submit required reports.

439B.655 Request by manufacturer, wholesaler or pharmacy benefit manager to keep certain information confidential as a trade secret; procedures for Authority to follow upon receipt of public records request for disclosure.

439B.660 Requirements for data and information included in report compiled by Authority concerning price of certain drugs.

439B.665 Appointment of hearing officers.

439B.670 Notice of intent to impose administrative penalty; accrual of administrative penalty.

439B.675 Appeals.

439B.680 Hearing on appeal.

439B.685 Failure to appear; recess; continuance.

439B.690 Order or decision; judicial review.

PAYMENT FOR MEDICALLY NECESSARY EMERGENCY SERVICES PROVIDED OUT-OF-NETWORK

439B.700 Request for list of randomly selected arbitrators to arbitrate dispute over claim of less than $5000; effect of failure to submit request; review and approval.

439B.705 Selection of arbitrator; provision of information to arbitrator; determination.

439B.710 Request for list of randomly selected arbitrators to arbitrate dispute over claim of $5000 or more.

439B.715 Election to submit to provisions concerning payment for medically necessary emergency services provided out-of-network; withdrawal of election.

439B.720 Submission of information by providers of health care and third parties.

ALL-PAYER CLAIMS DATABASE

General Provisions

439B.800 Definitions.

439B.802 “Administrator” defined.

439B.804 “Advisory Committee” defined.

439B.806 “Claim” defined.

439B.808 “Covered person” defined.

439B.810 “Data submitter” defined.

439B.812 “Historical data” defined.

439B.814 “Third party” defined.

439B.816 “Cost of health care” interpreted.

All-Payer Claims Database Advisory Committee

439B.818 Membership; terms, compensation; Chair; meetings; quorum.

439B.820 Duties.

Collection and Validation of Data

439B.822 Applicability to certain federally-regulated third parties.

439B.824 Collection of historical data.

439B.826 Adoption by reference of All-Payer Claims Database - Common Data Layout.

439B.828 Registration of third parties and data submitters.

439B.830 Submission of data: Applicability to Medicaid and Children’s Health Insurance Program; form, contents, method and time of submission.

439B.832 Submission of data: Information included in certain submissions; historical data not required for denied claim; exception.

439B.834 Submission of data: De-identification; encryption.

439B.836 Conditions for acceptance of data; audits of data.

439B.838 Request for variance from validation of data.

439B.840 Request for extension of time to submit historical data.

439B.842 Notification of and addressing errors in previously accepted historical data.

Administrative Penalties

439B.844 Amount; imputation of violation to certain entities; notice; hearing.

_________

NOTE: Pursuant to the provisions of NRS 0.024, the sections added to chapter 439B by sections 2 to 6, inclusive, of LCB File No. R121-20 contained definitions that were deemed duplicative of those set forth in NRS 439B.605, 439B.610, 439B.615 and 439B.622, respectively, and were not codified in NAC in accordance with ch. 56, Stats. 2009, which contains the following provision not included in NRS:

“Sec. 2. The Legislative Counsel shall, in preparing supplements to the Nevada Administrative Code, appropriately change, move or remove any words and terms in the Nevada Administrative Code in a manner that the Legislative Counsel determines necessary to ensure consistency with the provisions of section 1 of this act [NRS 0.024].”

REVISER’S NOTE.

The regulation of the Director of the Department of Human Resources (now the Department of Human Services) filed with the Secretary of State on December 31, 1991, LCB File No. R168-91, contains several provisions not included in NAC. Those provisions:

1. Require each major hospital to submit to the Department within 5 days after the beginning of each calendar quarter a complete charge master that was in effect on the first day of the quarter;

2. Describe the required contents of the charge master;

3. Prohibit a major hospital from charging a patient for an item that is not included on its charge master or its supplemental listing for miscellaneous items, and from charging a higher amount than the amount shown on the charge master, without the approval of the Director; and

4. Establish procedures regarding the approval and disapproval of billed charges for items not included in the supplemental listing for miscellaneous items.

GENERAL PROVISIONS

REVISER’S NOTE.

Pursuant to the provisions of NRS 0.024, former NAC 439B.030, 439B.040, 439B.050, 439B.080, 439B.090, 439B.100, 439B.120, 439B.155, 439B.160, 439B.170 and 439B.190 contained definitions that were deemed duplicative of those set forth in NRS 439B.030, 439B.050, 439B.060, 439B.090, 439B.100, 439B.110, 439B.310, 439B.115, 439B.120, 439B.130 and 439B.150, respectively, and were removed from chapter 439B of NAC in accordance with ch. 56, Stats. 2009, which contains the following provision not included in NRS:

NAC 439B.010 Definitions. As used in this chapter, unless the context otherwise requires, the words and terms defined in NAC 439B.110 to 439B.185, inclusive, have the meanings ascribed to them in those sections.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88; A 1-2-90; 12-31-91; 10-20-93)

NAC 439B.110 “Hospital fiscal year” defined. “Hospital fiscal year” has the meaning ascribed to it in subsection 2 of NRS 439B.090.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88)

NAC 439B.130 “Inpatient” defined. “Inpatient” means a patient who:

1. Is formally admitted to a hospital;

2. Is assigned to a regularly maintained inpatient bed; and

3. Has an inpatient medical chart initiated by the hospital.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88)

NAC 439B.140 “Inpatient billed charges” defined. “Inpatient billed charges” means those billed charges which are attributable to the provision of inpatient care by a hospital.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88)

NAC 439B.150 “Inpatient net revenue” defined. “Inpatient net revenue” means the net revenue which is attributable to the provision of inpatient care by a hospital.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88)

NAC 439B.180 “Net revenue” defined. “Net revenue” has the meaning ascribed to it in NRS 439B.140.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88)

NAC 439B.185 “Operating budget” defined. “Operating budget” means a plan of financial operations embodying an estimate of proposed expenditures for a given period and the proposed means of financing such expenditures, and generally including at least the following information:

1. The period of the budget (inclusive dates);

2. Forecasted patient days;

3. Percentage of rate increase to be implemented;

4. Forecasted gross revenues;

5. Forecasted contractual allowances, bad debt and discounts;

6. Forecasted operating expense;

7. Forecasted income from hospital operations;

8. Forecasted nonoperating revenues;

9. Forecasted nonoperating expense; and

10. Forecasted total income or loss.

(Added to NAC by Dep’t of Human Resources, eff. 10-20-93)

FINANCIAL PRACTICES OF HOSPITALS

NAC 439B.220 Submission of quarterly reports.

1. Each hospital shall submit the following information not later than 30 days after each quarter:

(a) Financial reports in the form prescribed by the Department;

(b) Utilization reports in the form prescribed by the Department; and

2. The Department shall adopt forms and instructions for the quarterly financial and utilization reports to be filed pursuant to subsection 1.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88; A 1-2-90; 10-20-93)

NAC 439B.230 Submission of annual financial reports. Each year a hospital shall file with the Department:

1. A copy of the report required to be submitted by the hospital to the Health Care Financing Administration for the purpose of Medicare payments, commonly known as the Medicare Cost Report within 120 days after the end of the hospital’s Medicare fiscal year.

2. At least 30 days after the beginning of each hospital fiscal year, a proposed operating budget for the hospital for the hospital’s fiscal year.

3. Within 30 days of receipt by the hospital, a copy of any report by an independent auditor concerning a financial audit of the hospital’s operations.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88; A 10-20-93)

NAC 439B.240 Certification of financial reports; penalty for failure to submit information; request for extension of time.

1. The officers of a hospital shall certify that the financial reports required to be submitted by a hospital to the Department are, to the best of their knowledge and belief, accurate and complete.

2. Except as otherwise provided in subsection 3, any person who fails to submit information required pursuant to this chapter on the date for submission is subject to an administrative fine of up to $1,000 for each day the information is not submitted. The fine will be imposed after notice and a hearing pursuant to NAC 439B.520.

3. A person may request an extension to submit information required by this chapter if the request:

(a) Is received by the Department before the information is due; and

(b) Sets forth an adequate justification of the reasons for the delay and a proposed submission date.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88; A 10-20-93)

NAC 439B.250 Submission of copy of audit. Each hospital in this state with not more than 200 beds or which is subject to the provisions of chapter 450 of NRS shall submit to the Department a copy of its audit. The audit must be conducted by an independent auditor at least annually. The hospital shall submit a copy of the audit within 30 days after receipt by the hospital of the audit from its auditor.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88)

NAC 439B.260 Independent audits; penalty for failure to cooperate.

1. The Director shall contract at least biennially with an independent auditing firm to conduct an examination of each hospital in this state with more than 200 beds which is not subject to the provisions of chapter 450 of NRS to ensure compliance with this chapter. The Director shall determine the scope of the examination for each hospital.

2. The auditor shall conduct the examination to determine whether the hospital is in full compliance with this chapter.

3. The auditor shall maintain separate accounts of the costs of the audit for each hospital. Each hospital subject to the audit shall pay the costs of the audit.

4. A hospital may contract with the auditing firm appointed by the Department for other work in the hospital in connection with the audit.

5. Any person who fails to submit information to the auditor upon request or who fails to submit to the audit is subject to an administrative fine of up to $1,000 for each day the person fails to submit the information or submit to the audit. The Director may impose the fine after notice and a hearing pursuant to NAC 439B.520.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88; A 10-20-93)

MAJOR HOSPITALS

NAC 439B.325 Major hospital to provide disclosure to patient who does not have medical insurance; effect of discount on prior arrangement to pay; circumstances entitling hospital to recover discount.

1. A major hospital which is required to reduce or discount the total billed charge for hospital services provided to an inpatient pursuant to NRS 439B.260 shall provide each patient who informs the hospital that he or she does not have medical insurance or other coverage to pay for inpatient services with a written disclosure approved by the Director explaining:

(a) That the patient may be entitled to receive a reduction or discount on the total billed charge; and

(b) How to apply for such a reduction or discount.

2. For the purposes of NRS 439B.260:

(a) A person who “has no insurance or other contractual provision for the payment of the charge” includes a person who discovers after he or she is discharged from the hospital that he or she has no insurance or other contractual provision for the payment of the charge.

(b) “Total billed charge” means the itemized billing required pursuant to NRS 449.243 for each stay of a patient and any additional charges for inpatient hospital services for that stay which are discovered after the submission of the itemized billing.

3. A patient who qualifies for a discount must receive the discount regardless of any prior arrangement to pay, unless the prior arrangement would result in a lower total cost to the patient.

4. A major hospital may require a patient who requests a discount to sign an agreement which assigns to the hospital all benefits that are payable to the patient from medical insurance or other coverage with regard to the total billed charge. Regardless of whether the patient signs such an agreement, if either the hospital or the patient receives payment from a payer with regard to the total billed charge, the discount becomes void and the hospital is entitled to recover the amount of the discount from the patient or payer according to the terms of the coverage.

5. In addition to the right of recovery pursuant to subsection 4, if a patient fraudulently represents to a hospital that he or she does not have a payer, the hospital is entitled to any additional remedies provided by law.

6. For the purposes of this section, “payer” means an insurance company or other third-party organization which has a contractual obligation to pay for hospital services provided to a patient, including, without limitation, a program of public assistance provided by an agency of the local, State or Federal Government.

(Added to NAC by Dep’t of Human Resources, eff. 8-1-94)

NAC 439B.330 Determination of reasonableness of arrangement for payment; hospital to provide written notice of terms of arrangement and respective rights and obligations to patient; adjustment of monthly payments.

1. Except as otherwise provided in subsection 2, to be deemed reasonable, the arrangement for payment required pursuant to paragraph (c) of subsection 1 of NRS 439B.260 must include at least a monthly payment which is the greater of:

(a) Twenty-five dollars; or

(b) Five percent of the monthly gross income of the patient’s household, exclusive of income which is not paid in cash, or 25 percent of the monthly gross income of the patient’s household which exceeds 200 percent of the federal poverty level, whichever is less.

2. An arrangement for payment which is different than the arrangement set forth in subsection 1 will be deemed reasonable if it is mutually agreed upon by the hospital and the patient.

3. At the time an arrangement for payment is made, the hospital shall provide written notice to the patient disclosing the terms of the arrangement and the respective rights and obligations of the patient and the hospital. The notice must provide a space for the patient’s signature. The hospital shall require the patient to sign in the provided space as acknowledgment that he or she understands and agrees to the arrangement for payment. If the hospital is not able to obtain the signature of the patient, it must maintain a record of its good faith effort to obtain his or her signature.

4. A major hospital may review the financial situation of a patient and adjust his or her monthly payments not more than one time per year.

(Added to NAC by Dep’t of Human Resources, eff. 8-1-94)

NAC 439B.335 Initial payment from patient upon admittance to hospital.

1. A major hospital may require an initial payment from a patient who is admitted to the hospital.

2. If a patient elects to be admitted to a major hospital, the hospital may require an initial payment in addition to any other preadmission deposits or payments.

3. A major hospital shall not require an initial payment towards the total billed charge which exceeds:

(a) Two and one-half times the monthly payment determined pursuant to subsection 1 of NAC 439B.330; or

(b) Fifty percent of the unencumbered liquid assets of the household of the patient.

(Added to NAC by Dep’t of Human Resources, eff. 8-1-94)

NAC 439B.340 Determination of annual rate of interest on unpaid balance of total billed charge; effect of delinquent account; sale, assignment or transfer of right to balance due on account.

1. If a major hospital charges interest on the unpaid balance of the total billed charge of a patient, the annual rate of interest must be based on the balance due after any reductions or discounts. The interest rate must not exceed the statutory interest rate in effect on the date that the arrangement for payment is agreed upon.

2. If the account of a patient becomes delinquent by 30 days or more:

(a) Upon the first and second occurrences, the hospital shall provide written notice of the delinquency to the patient. If the delinquency is not cured within 10 days after the patient receives the notice, the hospital may revoke any discount that was provided to the patient and seek to accelerate payment on the account.

(b) Upon the third and subsequent occurrences, the hospital may revoke the discount and seek to accelerate payment without allowing the patient 10 days to cure the delinquency.

3. The sale, assignment or transfer of the right to the uncollected amount of the balance due on the account of a patient with a major hospital is subject to the terms and conditions of any agreement between the hospital and the patient. Any such sale, assignment or transfer is also subject to the provisions of subsection 2.

(Added to NAC by Dep’t of Human Resources, eff. 8-1-94)

CARE OF INDIGENT PATIENTS

General Requirements

NAC 439B.390 Applicability of certain provisions of NRS and NAC.

1. The provisions of NRS 439B.300 to 439B.340, inclusive, and NAC 439B.410 apply to any hospital with 100 or more beds.

2. If the number of licensed beds of a hospital expands to 100 or more, it becomes subject to the provisions of NRS 439B.300 to 439B.340, inclusive, and NAC 439B.410.

3. As of July 1, 1992, the provisions of NRS 439B.300 to 439B.340, inclusive, and NAC 439B.410 apply to the following hospitals:

(a) In Clark County:

(1) Desert Springs Hospital;

(2) Sunrise Hospital and Medical Center;

(3) Lake Mead Hospital and Medical Center;

(4) University Medical Center;

(5) Valley Hospital Medical Center; and

(6) Saint Rose Dominican Hospital; and

(b) In Washoe County:

(1) Saint Mary’s Regional Medical Center;

(2) Sparks Family Hospital; and

(3) Washoe Medical Center.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88; A 1-2-90; 10-20-93)

NAC 439B.410 Submission of copy of Medicare Cost Report and estimate of inpatient net revenue.

1. Each hospital shall, within 120 days after the end of the hospital’s Medicare fiscal year, submit to the Department a copy of the report required to be submitted to the Health Care Financing Administration for the purpose of Medicare payments, commonly known as the Medicare Cost Report, for each hospital fiscal year.

2. Each such hospital whose hospital fiscal year ends June 30, shall submit to the Department an estimate of its inpatient net revenue for its current hospital fiscal year not later than June 30 of each year.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88; A 10-20-93)

NAC 439B.420 Determination of minimum obligation.

1. The Department shall:

(a) For the purposes of determining 0.6 percent of a hospital’s inpatient net revenue for the hospital’s previous fiscal year pursuant to NRS 439B.320, use the report required to be submitted by the hospital pursuant to NAC 439B.410 for the most recent hospital fiscal year ending before July 1 in any year.

(b) Determine the amount of the hospital’s minimum obligation by:

(1) Dividing the amount shown as inpatient total patient revenues on line 25 of Worksheet G-2 of the 2552-89 Medicare Cost Report or comparable line on a subsequent Medicare Cost Report by the amount shown as the total of all total patient revenues on the same line;

(2) Multiplying the result of paragraph (a) by the amount reported as Net Patient Revenues on line 3 of Worksheet G-3 of that report to determine the hospital’s total inpatient net revenue; and

(3) Multiplying the result of paragraph (b) by 0.006.

2. The amount determined pursuant to paragraph (b) of subsection 1 is subject to an adjustment by the Department based upon the receipt of subsequent information or an audit or examination of the hospital. The adjustment must be made to the current or following year of the hospital’s obligation pursuant to this section.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88; A 10-20-93)

NAC 439B.430 Reports on actual and estimated minimum obligation; notification to board of county commissioners.

1. On or before July 31 of each fiscal year, the Department shall report to the affected hospitals and the boards of county commissioners of Clark and Washoe Counties:

(a) The actual minimum obligation for indigent care for each hospital located in the county with a hospital fiscal year ending on a date other than June 30; and

(b) The estimated minimum obligation for indigent care for each hospital located in the county with a hospital fiscal year ending on June 30.

2. Within 30 days after receipt of the report required to be submitted by NAC 439B.410 for each hospital with a hospital fiscal year ending June 30, the Department shall notify the board of county commissioners of the county in which the hospital is located of the hospital’s actual minimum obligation for indigent care as determined pursuant to NAC 439B.420. The Department shall notify the board of county commissioners of any adjustments made pursuant to subsection 2 of NAC 439B.420 within 30 days after the adjustment.

3. For the purposes of the determinations and reports which are required to be made by the Department pursuant to NRS 439B.420, the Department shall use the information provided in the report submitted to the Department by the county pursuant to that section.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88; A 10-20-93)

NAC 439B.435 Delivery to hospitals of reports on indigent patients treated. Each county that is subject to the provisions of NRS 439B.340 shall, at the time it provides the Department with the report required by that section, deliver a copy of the report to each hospital affected thereby.

(Added to NAC by Dep’t of Human Resources, eff. 1-9-89; A 10-20-93)

Appeal of Determination of Indigent Status

NAC 439B.441 Applicability. A hospital appealing a determination of a county regarding the indigent status of an inpatient pursuant to subsection 4 of NRS 439B.330 shall comply with the provisions of NAC 439B.441 to 439B.449, inclusive.

(Added to NAC by Dep’t of Human Resources, eff. 9-16-92)

NAC 439B.442 Exhaustion of administrative procedures. A hospital must exhaust all available administrative procedures with a county before filing an appeal of a determination of a county regarding the indigent status of an inpatient with the Director or the person designated by the Director to hear such an appeal.

(Added to NAC by Dep’t of Human Resources, eff. 9-16-92)

NAC 439B.443 Filing and contents of appeal; submission of additional material upon request.

1. An appeal of a determination of a county regarding the indigent status of an inpatient must be in writing and must be filed with the Director within 30 calendar days after the date the hospital receives written notification of the county’s final determination.

2. An appeal must include the following information and documentation:

(a) The name of the patient;

(b) The date or dates of service;

(d) A listing of all determinations made by the county regarding the claim, including the date and the reason for rejection;

(e) All correspondence between the hospital and the county regarding the application for verification of indigent status of the patient;

(f) Any other information submitted by the hospital to the county for consideration in making its determination; and

(g) A written explanation of the basis for believing that the county’s decision was clearly erroneous, arbitrary, capricious or an abuse of discretion.

3. In addition to the information and documentation required by subsection 2, the Director or a designee thereof may request additional information or documentation from the hospital. An appeal may be dismissed if the Director or the designee does not receive the additional information or documentation within 15 calendar days after the request is made.

(Added to NAC by Dep’t of Human Resources, eff. 9-16-92)

NAC 439B.444 Determination to hold hearing or to issue decision denying appeal without hearing. After considering the information and documentation specified in NAC 439B.443, the Director or the designee will:

1. Hold a hearing; or

2. Based upon a finding that the county acted properly in rejecting the application, render a written decision that the appeal is without merit.

(Added to NAC by Dep’t of Human Resources, eff. 9-16-92)

NAC 439B.446 Scheduling and notice of hearing. If the Director or the designee determines that a hearing on the indigent status of an inpatient is necessary, he or she will set a time and place for the hearing and send notice of the hearing to the hospital and the county by registered or certified mail. Unless all parties otherwise stipulate, the hearing must be held not less than 30 calendar days nor more than 60 calendar days after the date the appeal was received by the Director or the designee.

(Added to NAC by Dep’t of Human Resources, eff. 9-16-92)

NAC 439B.447 Presentation of evidence at hearing. At a hearing held pursuant to NAC 439B.446:

1. Except as otherwise provided in subsection 3, the hospital and the county may present evidence in support of their positions.

2. The Director or the designee may request any information or documentation that he or she deems necessary to render a decision on the appeal.

3. Except as otherwise provided in subsection 2, the hospital shall not present evidence other than the information and documentation specified in NAC 439B.443, unless it has shown to the satisfaction of the Director or the designee that the evidence is material and there is good cause for its failure to present the evidence to the county. The Director or the designee may consider the additional evidence or may order the hospital to submit the additional evidence to the county and remand the application to the county.

(Added to NAC by Dep’t of Human Resources, eff. 9-16-92)

NAC 439B.448 Issuance of decision after hearing. If a hearing is held pursuant to NAC 439B.446, the Director or the designee will render a written decision within 30 calendar days after the date of the hearing, or if additional information or documentation is requested at the hearing, the Director or the designee will render a written decision within 30 calendar days after receipt of such information.

(Added to NAC by Dep’t of Human Resources, eff. 9-16-92)

NAC 439B.449 Contents of decision issued after hearing; effect of decision issued without or after hearing.

1. The written decision of the Director or the designee rendered pursuant to NAC 439B.448 must:

(a) Affirm the county’s decision; or

(b) Reverse or remand the county’s decision, in whole or in part, if substantial rights of a hospital have been prejudiced because the county’s decision was:

(1) Clearly erroneous;

(2) Arbitrary;

(3) Capricious; or

(4) An abuse of discretion.

2. A written decision rendered pursuant to subsection 2 of NAC 439B.444 or pursuant to NAC 439B.448 is final and may be appealed pursuant to subsection 4 of NRS 439B.340.

(Added to NAC by Dep’t of Human Resources, eff. 9-16-92)

PROHIBITED CONTRACTS AND TRANSACTIONS

NAC 439B.455 Disclosure required of financial interest in facility or service to which patient referred. A health facility shall not refer a patient to a health facility or service in which the referring party has a financial interest unless the health facility first provides the patient with a written statement disclosing that interest.

(Added to NAC by Dep’t of Human Resources, eff. 1-2-90; A 3-9-94)

NAC 439B.470 Procedure to determine whether prohibited contract between hospital and practitioner exists.

1. The Department shall:

(a) Establish a schedule for the submission of a listing of all contracts between a hospital or a related entity and a practitioner. The listing must indicate with respect to each contract:

(1) The type of contract, such as for rent, for services as a medical director, or for some other purpose;

(2) The practitioner’s name and address;

(3) The effective date of the contract; and

(4) The term of the contract.

(b) Request by registered mail the submission of the listing from hospitals pursuant to paragraph (a). Each hospital which receives such a request shall submit the listing within 30 days after receipt of the written request.

(c) Within 30 days after receipt of the listing from a hospital, schedule with the hospital an on-site review of the actual contracts, agreements and records concerning the contracts between the hospital or related entities and the practitioners. The hospital must submit copies of any contracts or agreements which the Department requests.

2. If a contract, agreement or record indicates that a violation of NRS 439B.420 may have occurred, the Director shall allow the hospital or any other party to an agreement with the hospital who is under investigation to provide additional information. The hospital shall provide that information within 30 days after receipt of the written notice from the Director informing the hospital or party that it may provide such additional information.

3. Within 30 days after receipt of the additional information or after the period for submitting the information has expired, the Director shall:

(a) If he or she determines that there is reason to believe a violation of NRS 439B.420 has occurred, schedule and hold a hearing pursuant to NAC 439B.520; or

(b) If he or she determines that there is not a sufficient reason to believe that a violation of NRS 439B.420 has occurred, notify the hospital in writing of his or her determination.

4. The failure of the Director to take action within the periods specified in subsection 2 or 3 of this section shall not be deemed an abandonment of the action or a determination that no violation occurred.

5. Unless a public hearing is held pursuant to subsection 3, all information submitted pursuant to this section is confidential. The Department shall not disclose that information to any person.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88; A 10-20-93)

NAC 439B.480 Contracts and agreements which must be listed and submitted to Department.

1. The following contracts and agreements must be included in the listing submitted to the Department by a hospital pursuant to NAC 439B.470:

(a) All rental agreements between the hospital or a related entity and a physician or entity which employs physicians;

(b) All agreements between the hospital or related entity and a physician or entity which employs physicians concerning the subsidization of rent by the hospital or related entity;

(c) All agreements between the hospital or a related entity and a practitioner for the hospital or a related entity acting as the billing agent of the practitioner;

(d) All agreements for the selling of goods or services from the hospital or related entity to a physician; and

(e) Such other agreements and information as the Director determines may be necessary to determine if a violation of NRS 439B.420 has occurred.

2. The hospital or related entity must submit to the Department copies of any contract or agreement requested by the Department.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88; A 10-20-93)

NAC 439B.490 Preliminary procedure to determine whether prohibited transaction between hospital and related entity has occurred.

1. The Department shall:

(a) Establish a schedule for the submission of a listing of all contracts and agreements between the hospitals and related entities pursuant to NRS 439B.430. The schedule must require the submission of the listing from each hospital at least biennially.

(b) Notify each hospital in writing at least 30 days before the date for submission of the listing of contracts and agreements between the hospital and its related entities. The Department shall specify in its notice the beginning and ending of the period for which the contracts and agreements will be reviewed.

2. A hospital shall, within 30 days after receipt of the written notice from the Department or the date for submission contained in the notice, whichever is later, submit the requested information to the Department. Unless an action is taken by the Department against the hospital to determine if a violation of NRS 439B.430 has occurred, all information submitted pursuant to this section is confidential. The Department shall not disclose the information to any person.

3. The Department shall, within 30 days after receipt of the listing from the hospital, schedule with the hospital an on-site review of the actual contracts, agreements and records concerning the contracts and agreements between a hospital and its related entities. The Department shall review the information and determine if there is reason to believe a violation of NRS 439B.430 has occurred.

4. If the Department determines that:

(a) There is reason to believe that a violation has occurred, it shall forward the information and its determination to the Director and notify the hospital in writing of its determination;

(b) There is no reason to believe a violation has occurred, it shall notify the hospital in writing of its determination; or

(c) Additional information is required to determine if a violation has occurred, it shall request the additional information from the hospital or its related entity. The hospital or its related entity shall provide the additional information within 30 days after receipt of the request therefor.

5. This section does not prohibit the Director from conducting an examination pursuant to subsection 3 of NRS 439B.430 at any time.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88; A 10-20-93)

NAC 439B.500 Determination by Director of whether prohibited transaction between hospital and related entity has occurred.

1. The Department shall forward to the Director any information which would support a determination that a violation of NRS 439B.430 has occurred.

2. Upon receipt of the information from any source which provides reason to believe that a violation of NRS 439B.430 has occurred, the Director shall allow the hospital to submit additional information from the hospital or related entity or any other party to an agreement with the hospital or related entity being investigated.

3. If the Director determines that there is:

(a) Reason to believe a violation of NRS 439B.430 has occurred, he or she shall schedule and hold a hearing pursuant to NAC 439B.520; or

(b) Not sufficient reason to believe that a violation of NRS 439B.430 has occurred, he or she shall notify the hospital of the determination in writing.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88; A 10-20-93)

NAC 439B.510 Reasonable cause to believe that prohibited transaction between hospital and related entity has occurred. Reasonable cause to believe that a violation of subsection 2 of NRS 439B.430 has occurred includes, but is not limited to:

1. The failure of a hospital or related entity to submit the copies required by NAC 439B.490 concerning an agreement, contract or transaction between the hospital and a related entity.

2. One or more related agreements, contracts or transactions between the hospital and its related entities resulting in:

(a) An increase in the hospital’s operating expenses;

(b) A decrease in the hospital’s net patient revenue; or

Ê of more than 1 percent from the previous fiscal year.

3. The value of the goods, services or consideration which is the subject of an agreement, contract or transaction between the hospital and a related entity being found to be materially different from the fair market value for similar agreements, contracts or transactions between nonrelated entities in the same area.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88)

NAC 439B.520 Hearing required before imposition of penalty.

1. Before imposing any financial penalty or other penalty pursuant to this chapter, the Director shall hold a hearing concerning the penalty.

2. The proceedings conducted pursuant to this section must be conducted pursuant to chapter 233B of NRS.

(Added to NAC by Dep’t of Human Resources, eff. 4-13-88; A 10-20-93)

REFERRALS BY PRACTITIONERS

REVISER’S NOTE.

Pursuant to the provisions of NRS 0.024, former NAC 439B.5302 and 439B.5308 contained definitions that were deemed duplicative of those set forth in NRS 439B.425 and were removed from chapter 439B of NAC in accordance with ch. 56, Stats. 2009, which contains the following provision not included in NRS:

NAC 439B.5205 Definitions. As used in NAC 439B.5205 to 439B.5408, inclusive, and for the purpose of enforcing the provisions of NRS 439B.425, unless the context otherwise requires, the words and terms defined in NAC 439B.5207 to 439B.540, inclusive, have the meanings ascribed to them in those sections.

(Added to NAC by Dep’t of Human Resources, eff. 3-9-94)

NAC 439B.5207 “Commercial establishment” defined. “Commercial establishment” means any business entity that provides goods or services other than a medical laboratory or a health facility.

(Added to NAC by Dep’t of Human Resources, eff. 3-9-94)

NAC 439B.530 “Financial interest” defined.

1. Except as otherwise provided in paragraph (f) of subsection 2 of NRS 439B.425, “financial interest” means an ownership or other interest:

(a) That provides compensation based, in whole or in part, upon the volume or value of goods or services provided as a result of referrals; and

(b) Which a practitioner or a person related to the practitioner within two degrees of consanguinity or affinity:

(1) Owns, in whole or in part; or

(2) Holds as a beneficiary of a trust.

2. The term includes, but is not limited to:

(a) A financial kickback, referral fee or finder’s fee.

(b) An income-sharing agreement, debt instrument, or lease or rental agreement that provides compensation based, in whole or in part, upon the volume or value of the goods or services provided as a result of referrals.

(Added to NAC by Dep’t of Human Resources, eff. 3-9-94)

NAC 439B.5304 “Medical laboratory” defined. “Medical laboratory” has the meaning ascribed to it in NRS 652.060.

(Added to NAC by Dep’t of Human Resources, eff. 3-9-94)

NAC 439B.5306 “One parcel of land” defined. “One parcel of land” means one conveyable lot or parcel of land or multiple conveyable lots or parcels of land which are contiguous.

(Added to NAC by Dep’t of Human Resources, eff. 3-9-94)

NAC 439B.540 “Refer” defined. “Refer” means sending or directing any person to another person or business entity for the purpose of obtaining, consuming or purchasing, for consideration, goods or services related to health care.

(Added to NAC by Dep’t of Human Resources, eff. 3-9-94)

NAC 439B.5402 Prohibited referral of patients by agent, employee or independent contractor of practitioner. The provision of subsection 1 of NRS 439B.425 prohibiting a practitioner from referring a patient, for a service or for goods related to health care, to a health facility, medical laboratory or commercial establishment in which the practitioner has a financial interest, must be construed as prohibiting any agent, employee or independent contractor of a practitioner from referring a patient of the practitioner, for a service or for goods related to health care, to a health facility, medical laboratory or commercial establishment in which the practitioner has a financial interest.

(Added to NAC by Dep’t of Human Resources, eff. 3-9-94)

NAC 439B.5404 Authorized referrals. The following referrals do not present a perception of a conflict of interest, are consistent with the overall purpose of chapter 439B of NRS and are not prohibited by the provisions of NRS 439B.425:

1. Any referral within one or more locations of a business entity if:

(a) The goods or services provided as a result of the referral are routinely provided to all patients of the referring practitioner based on their needs;

(b) The referring practitioner has the right to see regular patients for personal medical care, consultations, diagnoses and treatment at the same site and general location where the goods or services will be provided as a result of the referral;

(c) The goods and services provided as a result of the referral are billed as part of the bill provided by the referring practitioner or the business entity;

(d) The goods or services provided as a result of the referral are not provided at a facility operating under a different name; and

(e) The referral is not a referral by a licensed physician to a medical laboratory:

(1) In which the physician has a financial interest; and

(2) That is not operated solely in connection with the diagnosis or treatment of the physician’s patients.

2. Any referral within one or more locations of a business entity if:

(a) The goods or services provided as a result of the referral are not provided at a facility operating under a different name; and

(b) The referral does not result in any revenue for the referring practitioner, except in the form of additional net profit of a business:

(1) That is based upon a formula reflective of the referring practitioner’s percentage of ownership; and

(2) That is incidentally increased by the referral.

3. A referral made to a renal dialysis center for the treatment of end-stage renal disease.

4. A referral of a patient who is covered under a capitated insurance program, if the referral does not result in any additional revenue for either the referring practitioner or the business entity to which the patient is referred.

(Added to NAC by Dep’t of Human Resources, eff. 3-9-94; A 7-7-94)

NAC 439B.5406 Authorized referrals to facilities in which practitioner has financial interest.

1. The provisions of NRS 439B.425 do not prohibit a practitioner from referring a patient, for a service or for goods related to health care, to a health facility, medical laboratory or commercial establishment in which the practitioner has a financial interest if the referral is made on or before June 30, 1994, and:

(a) The financial interest existed on or before June 30, 1993;

(b) The practitioner files with the Director, on or before December 31, 1993, a form provided by the Department for the purpose of declaring a financial interest and requesting the authority to make the referral until June 30, 1994;

(c) The practitioner cures any defect in the form filed pursuant to paragraph (b) within 15 days from the date of postage of the notice of that defect provided by the Director pursuant to subsection 4; and

(d) The practitioner provides to each referred patient a written notice of his or her financial interest in any goods or services to be provided as a result of the referral.

2. The provisions of NRS 439B.425 do not prohibit a practitioner who, pursuant to subsection 1, has the authority to make a referral until June 30, 1994, from referring a patient, for a service or for goods related to health care, to a health facility, medical laboratory or commercial establishment in which the practitioner has a financial interest if the referral is made on or before December 31, 1994, and:

(a) The practitioner files with the Director, on or before May 31, 1994, a form provided by the Department for the purpose of requesting the authority to make the referral until December 31, 1994;

(b) The practitioner cures any defect in the form filed pursuant to paragraph (a) within 15 days from the date of postage of the notice of that defect provided by the Director pursuant to subsection 4;

(c) The practitioner submits an affidavit testifying that there has been a good faith effort to divest the financial interest or otherwise come into compliance with NRS 439B.425 and setting forth the practitioner’s plan to divest the financial interest; and

(d) The practitioner provides to each referred patient a written notice of his or her financial interest in any goods or services to be provided as a result of the referral.

3. For any request for the authority to make a referral pursuant to subsection 2, the Director will notify the practitioner in writing of his or her decision on or before June 30, 1994.

4. If there is any defect in a form submitted pursuant to paragraph (b) of subsection 1 or paragraph (a) of subsection 2, the Director will provide notice of the defect to the practitioner by mail.

(Added to NAC by Dep’t of Human Resources, eff. 3-9-94)

NAC 439B.5408 Investigation of possible prohibited referral by practitioner; determination by Director after investigation.

1. If the Department becomes aware of a possible violation of subsection 1 of NRS 439B.425, it may investigate the violation or forward the information to the applicable licensing board of the practitioner.

2. If, after an investigation is conducted pursuant to subsection 1, the Director determines that there is:

(a) Sufficient reason to believe a violation of subsection 1 of NRS 439B.425 has occurred, he or she will schedule and hold a hearing pursuant to chapter 233B of NRS. If, at the hearing, it is found that a violation of subsection 1 of NRS 439B.425 has occurred, the Director may impose a fine pursuant to subsection 2 of NRS 439B.450.

(b) Not sufficient reason to believe that a violation of subsection 1 of NRS 439B.425 has occurred, he or she will notify the practitioner of the determination in writing.

(Added to NAC by Dep’t of Human Resources, eff. 3-9-94)

EDUCATIONAL PROGRAM TO PROMOTE WELLNESS, PHYSICAL FITNESS AND PREVENTION OF DISEASE AND ACCIDENTS

NAC 439B.550 Development and implementation of program. An educational program developed pursuant to NRS 439B.280 must be designed to address problems or objectives related to health that are identified in National Health Promotion and Disease Prevention Objectives for the Year 2000, published by the United States Public Health Service. The major hospitals must determine the form and content of each program, but a program must be approved by the Director before it is implemented.

(Added to NAC by Dep’t of Human Resources, eff. 12-31-91)

NAC 439B.555 Description of program: Submission to Director; contents. At least 30 days before initiating an educational program pursuant to NRS 439B.280, the major hospitals shall submit to the Director a description of the program, including:

1. The name of the person responsible for liaison with the Director regarding the program;

2. Each problem or objective identified in National Health Promotion and Disease Prevention Objectives for the Year 2000 that the program is intended to address;

3. A syllabus or outline of the content of the program, indicating the major points to be conveyed, other significant points to be conveyed and the organization or sequence of presentation; and

4. Biographical sketches of the instructors, facilitators or leaders, indicating their professional competence to instruct in the relevant subject areas. If the instructors, facilitators or leaders for the program have not been selected at the time the plan is submitted to the Director, a brief statement of required professional qualifications must be included.

(Added to NAC by Dep’t of Human Resources, eff. 12-31-91)

NAC 439B.560 Description of program: Accompanying statement. The description of an educational program submitted pursuant to NAC 439B.555 must be accompanied by a statement from the major hospitals that:

1. If participation in or benefit from any part of the program is contingent upon the payment of a fee or the purchase of goods or services from one of the major hospitals or a facility affiliated with a major hospital, no prospective participant will be denied such participation or benefit on the basis of failure or inability to pay the required fee or charges.

2. Prospective participants will not be discriminated against on the basis of race, color, religion, national origin, sex or sexual orientation except to the extent such discrimination is clearly directed against persons or classes of persons who would not benefit from the program.

(Added to NAC by Dep’t of Human Resources, eff. 12-31-91)

NAC 439B.565 Notification by Director of decision regarding program; opportunity to make corrections. The Director will notify the person designated as liaison for a proposed educational program of his or her decision within 15 days after his or her receipt of the description of the program. If the program is disapproved, the Director’s notice will specify the required corrections and the hospitals will have an additional 15 days after the date of receipt of the notice of disapproval to make those corrections.

(Added to NAC by Dep’t of Human Resources, eff. 12-31-91)

PETITION FOR DECLARATORY ORDER OR ADVISORY OPINION

NAC 439B.600 Applicability. Any person or entity that is or may be subject to a provision of chapter 439B of NRS, or any regulation or prior decision of the Director of the Department or the Director of the Authority adopted pursuant thereto, may file with the Director of the Department or the Director of the Authority, as applicable to the provision, regulation or decision, a petition, in letter form, for a declaratory order or advisory opinion as to the applicability and interpretation of the provision to the person or entity. The petition must be filed by mailing the petition to the State of Nevada, Director of the Department of Human Services, Kinkead Building, Room 600, 505 East King Street, Carson City, Nevada 89710, by certified mail with a return receipt requested.

(Added to NAC by Dep’t of Human Resources, eff. 7-7-94)

NAC 439B.610 Contents of petition. A petition for a declaratory order or advisory opinion filed pursuant to NAC 439B.600 must include:

1. A statement of each issue upon which the petitioner is seeking a declaratory order or advisory opinion, including references to the provision of any statute, regulation or prior decision of the Director of the Department or Director of the Authority which the petitioner believes is at issue.

2. A statement of the factual circumstances that relate to the issues upon which the petitioner is seeking a declaratory order or advisory opinion, including, but not limited to:

(a) The type of business involved and the goods and services delivered, if any;

(b) A list of persons and entities with an existing or proposed financial interest in the business involved, the type of financial interest held by these persons or entities, including any interest in an executed or proposed contract, agreement or arrangement and an explanation of the role of these persons or entities in the delivery of goods and services delivered; and

(c) A flow chart of the business involved that shows the existing and proposed ownership, structure of business operations, locations of major equipment or laboratories, names of each entity or facility and patterns of referral among each practitioner, entity or facility involved.

3. A statement of the factual circumstances demonstrating how the existing and proposed structure of the business involved:

(a) Promotes equal access to quality medical care at an affordable cost;

(b) Reduces the cost of medical care through an improved competitive market; and

(Added to NAC by Dep’t of Human Resources, eff. 7-7-94)

NAC 439B.620 Powers of Director: Designation of person to issue declaratory order or advisory opinion; consolidation of petitions for advisory opinions.

1. The Director of the Department or Director of the Authority may designate a person within the Department or Authority, as applicable, to issue a declaratory order or advisory opinion pursuant to NAC 439B.600 to 439B.640, inclusive.

2. The Director of the Department or Director of the Authority or his or her designee thereof may issue a declaratory order that consolidates two or more petitions for an advisory opinion.

(Added to NAC by Dep’t of Human Resources, eff. 7-7-94)

NAC 439B.630 Issuance of declaratory order or advisory opinion: Time for issuance; tolling of time for issuance; consolidated petitions.

1. Except as otherwise provided in subsections 2 and 3, the Director of the Department or Director of the Authority, or his or her designee, will issue a declaratory order or advisory opinion pursuant to NAC 439B.600 to 439B.640, inclusive, within 60 days after the date on which a petition for a declaratory order or petition for an advisory opinion is filed.

2. The running of the time period for the issuance of a declaratory order or advisory opinion provided in subsection 1 shall be deemed to be tolled under the following circumstances:

(a) If the Director of the Department or Director of the Authority, or his or her designee, requests that the petitioner submit additional information to the Director of the Department or Director of the Authority, or his or her designee, after the date the petition for a declaratory order or advisory opinion was filed. The running of the time period for the issuance of a declaratory order or advisory opinion provided in subsection 1 shall be deemed to be tolled from the date the Director of the Department or Director of the Authority, or his or her designee, mails the request for additional information to the petitioner until 30 days after the date on which the Director of the Department or Director of the Authority, or his or her designee, receives the additional information from the petitioner.

(b) If the petitioner, without receiving a request for additional information from the Director of the Department or Director of the Authority, or his or her designee, submits additional information to the Director of the Department or Director of the Authority, or his or her designee, after the date the petition for a declaratory order or advisory opinion was filed. The running of the time period for the issuance of a declaratory order or advisory opinion provided in subsection 1 shall be deemed to be tolled from the date the additional information is received until 30 days after the date on which the Director of the Department or Director of the Authority, or his or her designee, receives the additional information from the petitioner.

3. When the Director of the Department or Director of the Authority, or his or her designee, decides to consolidate two or more petitions for an advisory opinion and issue a declaratory order, the Director of the Department or Director of the Authority, or his or her designee, will set a date for the issuance of the declaratory order which will allow for proper consideration of the issues and which may reasonably exceed 60 days after the dates on which each petition for an advisory opinion to be consolidated was filed. The Director of the Department or Director of the Authority, or his or her designee, will notify each petitioner by mail of the date set for the issuance of the declaratory order.

(Added to NAC by Dep’t of Human Resources, eff. 7-7-94)

NAC 439B.640 Copy of declaratory order or advisory opinion to be mailed to petitioner and made available to public. Upon the issuance of a declaratory order or advisory opinion pursuant to NAC 439B.600 to 439B.640, inclusive, the Director of the Department or Director of the Authority, or his or her designee, will mail a copy of the declaratory order or advisory opinion to the petitioner and will make a copy of the declaratory order or advisory opinion available to the public for inspection.

(Added to NAC by Dep’t of Human Resources, eff. 7-7-94)

REPORTING OF CERTAIN INFORMATION RELATING TO PRESCRIPTION DRUGS

NAC 439B.650 Authority to make available on Internet website forms for manufacturer, wholesaler, pharmacy benefit manager and pharmaceutical sales representative to submit required reports. (NRS 439B.685) The Authority will make available on an Internet website maintained by the Authority the forms on which:

1. A manufacturer is required to submit the reports required by NRS 439B.635 and 439B.640.

2. A wholesaler is required to submit the report required by NRS 439B.642.

3. A pharmacy benefit manager is required to submit the report required by NRS 439B.645.

4. A person included on a list of pharmaceutical sales representatives provided by a manufacturer to the Authority pursuant to subsection 1 of NRS 439B.660, is required to submit the report required by subsection 4 of that section.

(Added to NAC by Dep’t of Health & Human Services by R042-18, eff. 5-31-2018; A by R121-20, 6-13-2022)—(Substituted in revision for NAC 439.730)

NAC 439B.655 Request by manufacturer, wholesaler or pharmacy benefit manager to keep certain information confidential as a trade secret; procedures for Authority to follow upon receipt of public records request for disclosure. (NRS 439B.685)

1. In complying with NRS 439B.635, 439B.640, 439B.642 or 439B.645, if a manufacturer, wholesaler or pharmacy benefit manager reasonably believes that public disclosure of information that it submits to the Authority would constitute misappropriation of a trade secret for which a court may award relief pursuant to the federal Defend Trade Secrets Act of 2016, 18 U.S.C. § 1836, as amended, the manufacturer, wholesaler or pharmacy benefit manager may submit to the Authority a request to keep the information confidential.

2. A request for confidentiality submitted pursuant to subsection 1 must be divided into the following parts, which must be severable from each other:

(a) The first part of the request for confidentiality must describe, with particularity, the information sought to be protected from public disclosure. Upon a request for public records pursuant to NRS 239.010, the Authority will not disclose the description set forth in the request for confidentiality or the information sought to be protected from public disclosure, unless the description and information are disclosed pursuant to subsections 5 and 6.

(b) The second part of the request for confidentiality must include an explanation of the reasons why public disclosure of the information would constitute misappropriation of a trade secret for which a court may award relief pursuant to the federal Defend Trade Secrets Act of 2016, 18 U.S.C. § 1836, as amended. Upon a request for public records pursuant to NRS 239.010, the Authority will disclose the explanation set forth in the request for confidentiality.

3. If the Authority receives a request for public records pursuant to NRS 239.010 seeking disclosure of any information for which a manufacturer, wholesaler or pharmacy benefit manager has submitted a request for confidentiality pursuant to subsection 1, the Authority will:

(a) As soon as reasonably practicable after receiving the request for public records, provide the manufacturer, wholesaler or pharmacy benefit manager with:

(1) Written notice of the request for public records and the procedures set forth in this section; and

(2) A copy of the request for public records and the date on which the Authority received the request.

(b) Undertake an initial review to determine whether the Authority reasonably believes that public disclosure of the information would constitute misappropriation of a trade secret for which a court may award relief pursuant to the federal Defend Trade Secrets Act of 2016, 18 U.S.C. § 1836, as amended. In undertaking its initial review, the Authority will consider, as persuasive authority, the interpretation and application given to the term “trade secrets” in Exemption 4 of the federal Freedom of Information Act, 5 U.S.C. § 552(b)(4), as amended.

4. If, after undertaking its initial review pursuant to subsection 3, the Authority reasonably believes that public disclosure of the information would constitute misappropriation of a trade secret for which a court may award relief pursuant to the federal Defend Trade Secrets Act of 2016, 18 U.S.C. § 1836, as amended, the Authority will:

(a) Within the time prescribed by NRS 239.0107, provide the requester of the public records with written notice pursuant to paragraph (d) of subsection 1 of NRS 239.0107 that the Authority must deny the request for public records on the basis that the information is confidential pursuant to the federal Defend Trade Secrets Act of 2016, 18 U.S.C. § 1836, as amended.

(b) As soon as reasonably practicable after providing the written notice to the requester pursuant to paragraph (a), provide the manufacturer, wholesaler or pharmacy benefit manager with:

(1) Written notice that the Authority denied the request for public records; and

(2) A copy of the written notice that the Authority provided to the requester pursuant to paragraph (a) and the date on which the Authority sent the written notice to the requester.

5. If, after undertaking its initial review pursuant to subsection 3, the Authority reasonably believes that public disclosure of the information would not constitute misappropriation of a trade secret for which a court may award relief pursuant to the federal Defend Trade Secrets Act of 2016, 18 U.S.C. § 1836, as amended, the Authority will:

(a) Within the time prescribed by NRS 239.0107, provide the requester of the public records with written notice pursuant to paragraph (c) of subsection 1 of NRS 239.0107 that the Authority intends to disclose the information, except that:

(1) The Authority will not be able to disclose the information until 30 days have elapsed following the date on which such written notice was sent to the requester; and

(2) If the manufacturer, wholesaler or pharmacy benefit manager timely commences an action within the 30-day period as provided in subsection 6, the Authority will not be able to disclose the information, unless the disclosure is permitted by that subsection.

(b) As soon as reasonably practicable after providing the written notice to the requester pursuant to paragraph (a), provide the manufacturer, wholesaler or pharmacy benefit manager with:

(1) Written notice that the Authority intends to disclose the information; and

(2) A copy of the written notice that the Authority provided to the requester pursuant to paragraph (a) and the date on which the Authority sent the written notice to the requester.

6. If, within the 30-day period following the date on which the Authority sent the written notice to the requester of public records pursuant to subsection 5, the manufacturer, wholesaler or pharmacy benefit manager:

(a) Does not commence an action in a court of competent jurisdiction to enjoin the Authority from disclosing the information pursuant to the federal Defend Trade Secrets Act of 2016, 18 U.S.C. § 1836, as amended, the Authority will disclose the information.

(b) Commences an action in a court of competent jurisdiction to enjoin the Authority from disclosing the information pursuant to the federal Defend Trade Secrets Act of 2016, 18 U.S.C. § 1836, as amended, the Authority will not disclose the information until final resolution of the action, including any appeals. After final resolution of the action, if the court:

(1) Enjoins the Authority from disclosing the information as a trade secret, the Authority will not disclose the information so long as the information retains its status as a trade secret.

(2) Does not enjoin the Authority from disclosing the information as a trade secret, the Authority will disclose the information as soon as reasonably practicable after final resolution of the action.

(Added to NAC by Dep’t of Health & Human Services by R042-18, eff. 5-31-2018; A by R121-20, 6-13-2022)—(Substituted in revision for NAC 439.735)

NAC 439B.660 Requirements for data and information included in report compiled by Authority concerning price of certain drugs. (NRS 439B.685) In the report compiled by the Authority pursuant to NRS 439B.650, the Authority will include:

1. Only aggregated data that does not disclose the identity of any drug, manufacturer, wholesaler or pharmacy benefit manager; and

2. In addition to the information required by NRS 439B.650, a description of trends concerning the prices of prescription drugs that appear on the most current lists compiled by the Authority pursuant to NRS 439B.630, and an explanation of how those prices and trends may affect:

(a) The prevalence and severity of diabetes in this State; and

(b) The system of health care in this State.

(Added to NAC by Dep’t of Health & Human Services by R042-18, eff. 5-31-2018; A by R121-20, 6-13-2022)—(Substituted in revision for NAC 439.740)

NAC 439B.665 Appointment of hearing officers. (NRS 439B.685, 439B.695)

1. The Director of the Authority shall appoint three permanent employees of the Authority to serve as hearing officers.

2. An employee appointed as a hearing officer pursuant to this section shall perform the duties of a hearing officer in addition to the regular duties of the employee.

(Added to NAC by Dep’t of Health & Human Services by R121-20, eff. 6-13-2022)

NAC 439B.670 Notice of intent to impose administrative penalty; accrual of administrative penalty. (NRS 439B.685, 439B.695)

1. If the Authority intends to impose an administrative penalty pursuant to NRS 439B.695, the Authority will notify in writing the pharmacy, manufacturer, wholesaler, pharmacy benefit manager, nonprofit organization or pharmaceutical sales representative upon whom the administrative penalty is to be imposed at least 15 business days before the effective date of the administrative penalty. The notice must include, without limitation:

(a) A citation to the statutory and regulatory authority for the penalty;

(b) A description of the facts on which the penalty is based;

(d) Instructions for responding to the notice and a statement of the available appeal procedures, including, without limitation, a statement of the right to a hearing, the period during which a hearing must be requested and the consequences of waiving a hearing; and

(e) The effective date of the penalty.

2. The Authority will provide notice pursuant to this section to the last known physical address and last known electronic mail address of the pharmacy, manufacturer, wholesaler, pharmacy benefit manager, nonprofit organization or pharmaceutical sales representative upon whom the administrative penalty is to be imposed.

3. An administrative penalty imposed pursuant to NRS 439B.695 stops accruing on the day on which the required information is submitted to the Authority.

(Added to NAC by Dep’t of Health & Human Services by R121-20, eff. 6-13-2022)

NAC 439B.675 Appeals. (NRS 439B.685, 439B.695)

1. To appeal an administrative penalty imposed pursuant to NRS 439B.695, a pharmacy, manufacturer, wholesaler, pharmacy benefit manager, nonprofit organization or pharmaceutical sales representative, as applicable, must submit a request for an appeal to the Director of the Authority not later than 15 business days after the date on which the notice was provided pursuant to NAC 439B.670. If the pharmacy, manufacturer, wholesaler, pharmacy benefit manager, nonprofit organization or pharmaceutical sales representative fails to request a hearing within that time, the pharmacy, manufacturer, wholesaler, pharmacy benefit manager, nonprofit organization or pharmaceutical sales representative, as applicable, shall be deemed to have waived the appeal and the penalty becomes effective on the date specified in the notice.

2. The Director of the Authority shall use a rotation of the hearing officers appointed pursuant to NAC 439B.665 when selecting a hearing officer to hear an appeal. Upon receiving a request for an appeal pursuant to subsection 1, the Director of the Authority shall select the next hearing officer in the rotation who does not have a conflict of interest and is not otherwise disqualified to hear the appeal.

3. The Authority will not attempt to collect a penalty while an appeal is pending.

(Added to NAC by Dep’t of Health & Human Services by R121-20, eff. 6-13-2022)

NAC 439B.680 Hearing on appeal. (NRS 439B.685, 439B.695)

1. Except as otherwise provided in this subsection, a hearing on an appeal requested pursuant to NAC 439B.675 must be open to the public. Upon the motion of a party, the hearing officer, in his or her discretion, may exclude from the hearing room any witness in the matter not at the time under examination except a party to the proceeding or his or her counsel.

2. The hearing officer shall determine the evidence upon the charges and specifications as set forth by the Authority in the notice provided pursuant to NAC 439B.670.

3. The technical rules of evidence do not apply. All testimony and exhibits offered must be relevant and bear upon the matter in contention. The hearing officer may exclude any testimony or exhibit that he or she determines does not meet this criterion. The hearing officer shall also consider the objection of either side to the introduction of evidence, whether oral testimony or exhibit. When ruling on the objection, the hearing officer shall primarily consider the competence and relevance of the evidence at issue.

4. The hearing officer shall base his or her decision on the weight of the evidence presented at the hearing. Findings of fact, conclusions of law and decisions must be based on substantial evidence.

5. At the beginning of his or her testimony, each witness who has not previously testified in the hearing shall state his or her name and business, employment or position.

6. Any letter, paper or object offered in evidence must be properly authenticated and, if received, must be marked by the hearing reporter with a distinguishing number or letter, such as “Authority’s Exhibit 1” or “Appellant’s Exhibit A.”

7. Testimony may be presented in statement or question and answer form.

8. With the approval of the hearing officer, the parties may stipulate as to any fact at issue, either by a written stipulation introduced in evidence as an exhibit or by oral statements shown upon the record. Any such stipulation is binding upon all parties so stipulating and may be regarded by the hearing officer as evidence at the hearing.

9. The Authority or an appellant may subpoena a witness to testify at a hearing. Such a witness must receive the fees and mileage allowed by law to a witness in a civil case.

10. The Authority will keep a record of the proceedings, but the record need not be transcribed unless the decision is appealed or a transcript is requested by an interested party. Any party who requests a transcript shall pay the cost of transcription.

(Added to NAC by Dep’t of Health & Human Services by R121-20, eff. 6-13-2022)

NAC 439B.685 Failure to appear; recess; continuance. (NRS 439B.685, 439B.695)

1. If a party fails to appear at a hearing scheduled by the hearing officer after receiving a request pursuant to NAC 439B.675 and no continuance has been granted:

(a) The hearing officer may hear the evidence and proceed to consider the matter and dispose of it on the basis of the evidence before the hearing officer; and

(b) The charges specified in the proposed finding are presumed to be true.

2. Upon determining that good cause exists for a recess, the hearing officer may recess a hearing until a future date agreeable to the hearing officer and the parties.

3. The hearing officer may, before or during a hearing, upon a proper showing, grant a continuance for the submission of additional proof or another reasonable purpose.

(Added to NAC by Dep’t of Health & Human Services by R121-20, eff. 6-13-2022)

NAC 439B.690 Order or decision; judicial review. (NRS 439B.685, 439B.695)

1. The hearing officer shall render an order or decision with separately stated findings of fact and conclusions of law after the completion of a hearing on an appeal pursuant to NAC 439B.680. A hearing is complete after the taking of evidence, the filing of briefs or the presentation of such oral or written arguments as may have been allowed by the hearing officer.

2. The decision of a hearing officer made pursuant to the procedures set forth in NAC 439B.665 to 439B.690, inclusive, is a final decision in a contested case. Any person aggrieved by such a decision is entitled to judicial review of the decision pursuant to NRS 233B.130.

(Added to NAC by Dep’t of Health & Human Services by R121-20, eff. 6-13-2022)

PAYMENT FOR MEDICALLY NECESSARY EMERGENCY SERVICES PROVIDED OUT-OF-NETWORK

NAC 439B.700 Request for list of randomly selected arbitrators to arbitrate dispute over claim of less than $5000; effect of failure to submit request; review and approval. (NRS 439B.754)

1. To request a list of randomly selected arbitrators pursuant to subsection 3 of NRS 439B.754 to arbitrate a dispute over a claim of less than $5,000, an out-of-network provider must submit a request to the Department. If the out-of-network provider submits the request because the third party has refused or failed to pay the additional amount requested by the out-of-network provider pursuant to subsection 2 of NRS 439B.754, the out-of-network provider must submit the request by:

(a) If the third party refused to pay the additional amount, not later than 30 business days after the date on which the third party notifies the out-of-network provider of the refusal.

(b) If the third party failed to pay the additional amount for 30 business days after receiving a request for the additional amount, not later than 30 business days after that date.

2. A request submitted pursuant to subsection 1 must be in the form prescribed by the Department and include, without limitation:

(a) The date on which the medically necessary emergency services to which the complaint pertains were provided and the type of medically necessary emergency services provided;

(b) The contact information for and location of the out-of-network provider that provided the medically necessary emergency services;

(d) The type of third party that provides coverage for the covered person to whom the medically necessary emergency services were rendered and contact information for that third party; and

(e) Documentation of:

(1) The date on which the out-of-network provider received payment from the third party pursuant to subsection 2 of NRS 439B.748 or paragraph (c) of subsection 1 or subsection 2 of NRS 439B.751, as applicable, and the amount of payment received;

(2) The date on which the out-of-network provider requested additional payment from the third party pursuant to subsection 2 of NRS 439B.754, and the additional amount requested; and

(3) The date on which the third party refused to pay the additional amount, if applicable.

3. If the Department does not receive a request pursuant to subsection 1 within the prescribed time, the out-of-network provider shall be deemed to have accepted the payment received from the third party pursuant to subsection 2 of NRS 439B.748 or paragraph (c) of subsection 1 or subsection 2 of NRS 439B.751, as applicable, as payment in full for the medically necessary emergency services.

4. Not later than 10 business days after receiving a request pursuant to subsection 1, the Department shall notify the out-of-network provider in writing of the receipt of the request. Not later than 20 business days after providing such notification, the Department shall:

(a) Review the request and verify the information contained therein; and

(b) Notify the out-of-network provider in writing of any additional information necessary to complete or clarify the request.

5. The Department will approve a request submitted pursuant to subsection 1 not later than 5 business days after determining that the request includes the documentation required by subsection 2 and is otherwise complete and clear. Not later than 5 business days after approving a request, the Department shall:

(a) Notify the out-of-network provider and the third party in writing of the approval.

(b) Randomly select five employees of the Office for Consumer Health Assistance of the Department who are qualified to arbitrate the dispute and ensure that those arbitrators do not have a conflict of interest that would prevent the arbitrator from impartially rendering a decision. For the purposes of this paragraph, a conflict of interest shall be deemed to exist if the arbitrator, or any person affiliated with the arbitrator:

(1) Has direct involvement in the licensing, certification or accreditation of a health care facility, insurer or provider of health care;

(2) Has a direct ownership interest or investment interest in a health care facility, insurer or provider of health care;

(3) Is employed by, or participating in, the management of a health care facility, insurer or provider of health care; or

(4) Receives or has the right to receive, directly or indirectly, remuneration pursuant to any arrangement for compensation with a health care facility, insurer or provider of health care.

(c) Provide to the out-of-network provider and the third party a written list of five arbitrators selected pursuant to paragraph (b) who have been determined not to have a conflict of interest.

(Added to NAC by Dep’t of Health & Human Services by R101-19, eff. 9-28-2022)

NAC 439B.705 Selection of arbitrator; provision of information to arbitrator; determination. (NRS 439B.754)

1. Not later than 10 business days after the Department provides a written list of arbitrators to an out-of-network provider and a third party pursuant to subsection 5 of NAC 439B.700, the out-of-network provider and third party shall strike arbitrators from the list in the manner required by subsection 4 of NRS 439B.754 and provide the name or names of any remaining arbitrators on the list in writing to the Department.

2. Not later than 10 business days after receiving the name of any remaining arbitrator on the list pursuant to subsection 1, the Department shall:

(a) If one arbitrator who does not have a conflict of interest remains, notify the out-of-network provider and the third party in writing of the name of that arbitrator.

(b) If more than one arbitrator who does not have a conflict of interest remains, randomly select an arbitrator from the remaining arbitrators as required by subsection 4 of NRS 439B.754 and notify the out-of-network provider and the third party in writing of the name of that arbitrator.

3. The out-of-network provider or third party may provide the arbitrator with any relevant information to assist the arbitrator in making a determination not later than 10 business days after the date on which the Department notifies the out-of-network provider and the third party in writing of the name of that arbitrator pursuant to subsection 2.

4. An arbitrator selected pursuant to subsection 2 may request from the third party and the out-of-network provider any information the arbitrator deems necessary to assist in making a determination. The out-of-network provider and third party shall provide such information to the arbitrator not later than 10 business days after the date of the request. If either party fails to provide information requested by the arbitrator within that time, the arbitrator may proceed and make a determination based on the evidence available to the arbitrator.

5. Not later than 45 business days after the expiration of the period for submission of the information pursuant to subsection 3 or 4, whichever is later, the arbitrator shall make a determination as provided in subsection 6 of NRS 439B.754 and notify the parties of that determination.

(Added to NAC by Dep’t of Health & Human Services by R101-19, eff. 9-28-2022)

NAC 439B.710 Request for list of randomly selected arbitrators to arbitrate dispute over claim of $5000 or more. (NRS 439B.754) An out-of-network provider that wishes to request a list of randomly selected arbitrators pursuant to subsection 3 of NRS 439B.754 to arbitrate a dispute over a claim of $5,000 or more must request a list of five randomly selected arbitrators from:

1. The American Arbitration Association or its successor organization; or

2. JAMS or its successor organization.

(Added to NAC by Dep’t of Health & Human Services by R101-19, eff. 9-28-2022)

NAC 439B.715 Election to submit to provisions concerning payment for medically necessary emergency services provided out-of-network; withdrawal of election. (NRS 439B.757)

1. To elect to have the provisions of NRS 439B.700 to 439B.760, inclusive, apply to an entity or organization that is not otherwise subject to those provisions as authorized pursuant to NRS 439B.757, the entity or organization must apply to the Department in the form prescribed by the Department. The application must include, without limitation:

(a) The name of and contact information for the entity or organization; and

(b) A description of the type of entity or organization, as applicable, that it is.

2. If an application is received pursuant to subsection 1:

(a) On or after the first day of any month and on or before the 14th day of that month, the election to have the provisions of NRS 439B.700 to 439B.760, inclusive, apply to the applicant becomes effective on the first day of the immediately following month.

(b) On or after the 15th day of any month and on or before the last day of that month, the election to have the provisions of NRS 439B.700 to 439B.760, inclusive, apply to the applicant becomes effective on the 15th day of the immediately following month.

3. Any entity or organization may withdraw its election to have the provisions of NRS 439B.700 to 439B.760, inclusive, apply to the entity or organization by submitting an application to the Department in the form prescribed by the Department not less than 120 business days before the date on which the withdrawal is requested to become effective. The application must include, without limitation:

(a) The name of and contact information for the entity or organization;

(b) A description of the type of entity or organization, as applicable, that it is;

(d) The reason for requesting to withdraw the election.

4. Any medically necessary emergency services to which an election pursuant to this section apply that are provided while the election is effective are subject to the provisions of NRS 439B.700 to 439B.760, inclusive.

(Added to NAC by Dep’t of Health & Human Services by R101-19, eff. 9-28-2022)

NAC 439B.720 Submission of information by providers of health care and third parties. (NRS 439B.760)

1. On or before December 31 of each year, each provider of health care who provides medically necessary emergency services in this State shall submit to the Department in the form prescribed by the Department:

(a) The name of and contact information for the provider of health care;

(b) A description of the type of provider of health care that it is;

(c) Whether there was an increase or decrease in the number of contracts with third parties entered into by the provider of health care during the immediately preceding 12 months and the amount of the increase or decrease, stated as a percentage; and

(d) For each new contract with a third party entered into by the provider of health care during the immediately preceding 12 months, the type of the third party.

2. On or before December 31 of each year, each third party that provides coverage to residents of this State shall submit to the Department in the form prescribed by the Department:

(a) The name of and contact information for the third party;

(b) A description of the type of third party that it is;

(c) Whether there was an increase or decrease in the number of contracts with providers of health care who provide medically necessary emergency services entered into by the third party during the immediately preceding 12 months and the amount of the increase or decrease, stated as a percentage; and

(d) For each new contract with a provider of health care who provides medically necessary emergency services entered into by the third party during the immediately preceding 12 months, the type of the provider of health care.

(Added to NAC by Dep’t of Health & Human Services by R101-19, eff. 9-28-2022)

ALL-PAYER CLAIMS DATABASE

General Provisions

NAC 439B.800 Definitions. (NRS 439B.835, 439B.875) As used in NAC 439B.800 to 439B.844, inclusive, unless the context otherwise requires, the words and terms defined in NAC 439B.802 to 439B.814, inclusive, have the meanings ascribed to them in those sections.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.802 “Administrator” defined. (NRS 439B.875) “Administrator” means the Office or the entity that is selected by the Office to manage the historical data in the all-payer claims database.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.804 “Advisory Committee” defined. (NRS 439B.835, 439B.875) “Advisory Committee” means the All-Payer Claims Database Advisory Committee created by NAC 439B.818.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.806 “Claim” defined. (NRS 439B.835, 439B.875) “Claim” means any communication that is used to identify specific goods, items or services that are reimbursable by a third party, or which states income or an expense, and is or may be used by a third party to determine a rate of payment. The term includes, without limitation, a bill or line item for services.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.808 “Covered person” defined. (NRS 439B.875) “Covered person” means a policyholder, subscriber, enrollee or other person covered by a third party.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.810 “Data submitter” defined. (NRS 439B.835, 439B.875)

1. “Data submitter” means:

(a) An entity that is required by subsection 1 of NRS 439B.840 or subsection 1 of NAC 439B.830 to submit historical data to the all-payer claims database.

(b) An entity described in subsection 2 of NRS 439B.840 that elects to submit historical data to the all-payer claims database.

(c) An entity which submits historical data to the all-payer claims database on behalf of an entity described in paragraph (a) or (b), including, without limitation:

(1) A pharmacy benefit manager, as defined in NRS 683A.174, or other third party administrator; or

(2) An insurer that pays for behavioral health services which are excluded from other health care plans.

2. The term does not include an entity described in subsection 2 of NRS 439B.840 that does not elect to submit historical data to the all-payer claims database.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.812 “Historical data” defined. (NRS 439B.835, 439B.875) “Historical data” means the data described in subsection 2 of NAC 439B.830.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.814 “Third party” defined. (NRS 439B.875) “Third party” means:

1. A health carrier, as defined in NRS 439B.840;

2. A governing body of a local governmental agency that provides health insurance through a self-insurance reserve fund pursuant to NRS 287.010;

3. Medicaid;

4. The Children’s Health Insurance Program;

5. The Public Employees’ Benefits Program;

6. A provider of health coverage for federal employees;

7. A provider of health coverage that is subject to the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1101 et seq.; and

8. The administrator of a Taft-Hartley trust formed pursuant to 29 U.S.C. § 186(c)(5).

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.816 “Cost of health care” interpreted. (NRS 439B.835, 439B.860, 439B.875) For the purposes of NRS 439B.860 and NAC 439B.820, the Office will interpret “cost of health care” to mean the final payment made to a provider of health care by:

1. An entity that is required by subsection 1 of NRS 439B.840 or subsection 1 of NAC 439B.830 to submit historical data to the all-payer claims database; or

2. An entity described in subsection 2 of NRS 439B.840 that elects to submit historical data to the all-payer claims database.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

All-Payer Claims Database Advisory Committee

REVISER’S NOTE.

The regulation of the Department of Health and Human Services (now the Department of Human Services) filed with the Secretary of State on November 15, 2024 (LCB File No. R104-23), the source of this section, contains the following provision not included in NAC:

“Sec. 25. This regulation is hereby amended by adding thereto the following transitory language which has the force and effect of law but which will not be codified in the Nevada Administrative Code:

1. Notwithstanding the provisions of section 11 of this regulation [NAC 439B.818], the Director of the Department of Health and Human Services [now the Department of Human Services] shall appoint to the initial membership of the All-Payer Claims Database Advisory Committee in place of the members described in paragraphs (g) and (h) of subsection 2 of section 11 of this regulation [NAC 439B.818]:

(a) One member who represents the data submitter that is responsible for the highest number of claims in this State during the immediately preceding 2 years, as reflected in the records of the Division of Insurance of the Department of Business and Industry; and

(b) One member who represents the data submitter that is responsible for the second-highest number of claims in this State during the immediately preceding 2 years, as reflected in the records of the Division of Insurance of the Department of Business and Industry.

2. As used in this section, “data submitter” has the meaning ascribed to it in section 7 of this regulation [NAC 439B.810].”

NAC 439B.818 Membership; terms, compensation; Chair; meetings; quorum. (NRS 439B.835)

1. The All-Payer Claims Database Advisory Committee is hereby created within the Office.

2. The Director of the Authority or his or her designee shall appoint the members of the Advisory Committee, subject to the requirements of subsection 3, as follows:

(a) One member who is a provider of health care;

(b) One member who represents a health facility;

(d) One member who represents a health maintenance organization, as defined in NRS 695C.030;

(e) One member who represents a private insurer;

(f) One member who represents a nonprofit organization that represents consumers of health care services;

(g) One member who represents the data submitter that submitted the highest number of claims to the all-payer claims database during the immediately preceding 2 years; and

(h) One member who represents the data submitter that submitted the second-highest number of claims to the all-payer claims database during the immediately preceding 2 years.

3. Each member of the Advisory Committee:

(a) Must be a resident of this State.

(b) Serves for a term of 2 years.

4. Members of the Advisory Committee serve without compensation, except that each member is entitled, while engaged in the business of the Advisory Committee, to the per diem allowance and travel expenses provided for state officers and employees generally, if money is available for that purpose.

5. The Director of the Authority or his or her designee shall appoint a Chair of the Advisory Committee from among its members to hold office for a term of 1 year.

6. The Advisory Committee shall meet at least three times in each calendar year and may meet at other times upon the call of the Director of the Authority or his or her designee, or the Chair.

7. A majority of the members of the Advisory Committee constitutes a quorum for the transaction of business, and a majority of a quorum present at any meeting is sufficient for any official action taken by the Advisory Committee.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.820 Duties. (NRS 439B.835) The Advisory Committee shall:

1. Make recommendations to the Office concerning:

(a) Specifications for the collection of historical data for the all-payer claims database;

(b) The analysis and reporting of historical data in the all-payer claims database;

(d) The secure release of historical data in the all-payer claims database pursuant to NRS 439B.800 to 439B.875, inclusive.

2. Annually submit to the Office a report concerning the quality, efficiency and cost of health care in this State.

3. Assist the Office in establishing and maintaining the all-payer claims database.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

Collection and Validation of Data

NAC 439B.822 Applicability to certain federally-regulated third parties. (NRS 439B.875) The provisions of NAC 439B.824 to 439B.842, inclusive, apply to an entity described in subsection 2 of NRS 439B.840 only to the extent that the entity elects to submit historical data to the all-payer claims database.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.824 Collection of historical data. (NRS 439B.875) The Office will collect historical data in accordance with the provisions of NRS 439B.800 to 439B.875, inclusive, and NAC 439B.824 to 439B.842, inclusive.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.826 Adoption by reference of All-Payer Claims Database - Common Data Layout. (NRS 439B.875)

1. The Office hereby adopts by reference the All-Payer Claims Database - Common Data Layout in the form most recently published by the All-Payer Claims Database Council, unless the Office gives notice that the most recent revision is not suitable for this State pursuant to subsection 2. A copy of the All-Payer Claims Database - Common Data Layout may be obtained, free of charge, from the All-Payer Claims Database Council at the Internet website https://www.apcdcouncil.org/apcd-cdltm/download-apcd-cdltm.

2. The Office will review each revision of the All-Payer Claims Database - Common Data Layout adopted by reference in subsection 1 to ensure its suitability for this State. If the Office determines that a revision is not suitable for this State, the Office will hold a public hearing to review its determination within 12 months after the date of the publication of the revision and give notice of that hearing. If, after the hearing, the Office does not revise its determination, the Office will give notice within 30 days after the hearing that the revision is not suitable for this State. If the Office does not give such notice, the revision becomes part of the publication adopted by reference in subsection 1.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.828 Registration of third parties and data submitters. (NRS 439B.875)

1. Not later than February 1 of each year, each third party that provides health coverage to residents of this State, including, without limitation, such a third party that is exempt pursuant to paragraph (a), (b) or (c) of subsection 1 of NRS 439B.840 from the requirement to submit data to the all-payer claims database, and each data submitter that will submit data to the all-payer claims database on behalf of a third party during that year shall register with the Office on a form prescribed by the Office.

2. The form must include, without limitation:

(a) The legal name of the registrant.

(b) The address of the registrant.

(1) The company code assigned to the insurer by the National Association of Insurance Commissioners; and

(2) The federal employer identification number of the insurer.

(d) For at least two persons who represent the registrant, the following information:

(1) The first and last name of each person;

(2) The title of each person;

(3) A telephone number for each person;

(4) An electronic mail address for each person; and

(5) A mailing address for each person.

(e) A complete list of the types of historical data, as specified in subsection 2 of NAC 439B.830, which the registrant is eligible to submit to the all-payer claims database.

(f) Any relationships between the registrant and:

(1) Any other entity on whose behalf the registrant will submit historical data to the all-payer claims database; or

(2) Any other data submitter that will submit historical data on behalf of an entity described in subparagraph (1).

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.830 Submission of data: Applicability to Medicaid and Children’s Health Insurance Program; form, contents, method and time of submission. (NRS 439B.875)

1. In addition to the entities described in subsection 1 of NRS 439B.840, Medicaid and the Children’s Health Insurance Program shall submit historical data to the all-payer claims database.

2. Each data submitter shall submit to the all-payer claims database in accordance with NAC 439B.824 to 439B.842, inclusive, the following historical data, to the extent applicable:

(a) Files of claims for covered medical services, including, without limitation, covered behavioral health services.

(b) Files of claims for covered pharmacy services.

(d) Files containing data relating to the eligibility for coverage and demographics of covered persons.

(e) Files containing data relating to providers of health care.

3. A data submitter shall submit historical data in the format prescribed by the All-Payer Claims Database - Common Data Layout, adopted by reference in NAC 439B.826.

4. A data submitter shall submit historical data through:

(a) The portal for collection of historical data for the all-payer claims database which is managed by the administrator; or

(b) A secure file transfer protocol site which is hosted by the administrator.

5. Each data submitter shall submit historical data for each calendar quarter not later than the first business day of the second month following the end of that calendar quarter.

6. The first time a data submitter submits historical data to the all-payer claims database, the data submitter shall submit historical data for the 3 calendar years immediately preceding that initial submission of historical data.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.832 Submission of data: Information included in certain submissions; historical data not required for denied claim; exception. (NRS 439B.875)

1. Except as otherwise provided in subsection 2, a data submitter that submits historical data relating to covered medical services, dental services or pharmacy services shall include information on all service lines for every claim paid or encounter processed during the reporting period for which the historical data is submitted, regardless of the location where the service was provided.

2. Except as otherwise provided in this subsection, a data submitter is not required to submit historical data pursuant to subsection 1 for a claim which is denied in its entirety. A data submitter shall submit historical data for a claim which was paid and reported to the all-payer claims database but is subsequently reversed or denied.

3. Files submitted to the all-payer claims database that contain historical data relating to providers of health care must include demographic data and other relevant data relating to each provider of health care who is referenced in historical data described in subsection 1 or 4, including, without limitation:

(a) Primary care providers;

(b) Rendering providers;

(d) Referring providers;

(e) Attending providers;

(f) Prescribing providers; and

(g) Pharmacies.

4. Files containing historical data relating to the eligibility for coverage and demographics of covered persons must include data for each covered person who resided in this State and was eligible for a defined set of benefits for 1 or more days within the reporting period. If a covered person is covered by more than one distinct policy, a record must be included for each policy. If the reporting period of the file spans multiple months, the covered person must be reported with one record per month of eligibility.

5. As used in this section, “encounter” means a covered service or group of services delivered by a provider to a covered person during a visit or as a result of a visit between the covered person and the provider.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.834 Submission of data: De-identification; encryption. (NRS 439B.875)

1. Each data submitter shall de-identify the historical data which it submits, including, without limitation, direct patient identifiers, by using a hashing algorithm prescribed and provided by the administrator. The administrator shall prescribe and provide to each data submitter a hashing algorithm which is recommended by the Federal Government.

2. A data submitter may, but is not required to, encrypt using Pretty Good Privacy encryption the historical data which the data submitter submits.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.836 Conditions for acceptance of data; audits of data. (NRS 439B.875)

1. Except as otherwise provided in NAC 439B.838 and 439B.840, the Office will only accept historical data which:

(a) Passes the validation described in subsection 2; and

(b) Is submitted by the deadline prescribed by NAC 439B.830 for the submission of historical data.

2. When conducting a validation pursuant to paragraph (a) of subsection 1, the Administrator shall use a process that meets the requirements of this section to ensure that the format and content of the historical data submitted by data submitters are valid and complete. The process must include, without limitation:

(a) A field-level audit conducted in accordance with subsection 3 when historical data is submitted;

(b) A quality audit conducted to determine whether the historical data meets the default threshold of reasonableness prescribed pursuant to paragraph (b) of subsection 4; and

(c) The consolidation of the data and a reasonableness, longitudinal and relational audit of the consolidated data to confirm whether the submission contains the appropriate amount of historical data for the number of persons covered by the data submitter.

3. A field-level audit conducted pursuant to paragraph (a) of subsection 2 must:

(a) Determine whether the historical data that is being audited is in the correct form and has been submitted using the hashing algorithm prescribed and provided pursuant to NAC 439B.834; and

(b) Evaluate whether the field length and type, code values and the percentage of the fields that are filled meet the thresholds for completeness and content prescribed pursuant to paragraph (a) of subsection 4.

4. The administrator shall prescribe:

(a) For use in each field-level audit conducted pursuant to paragraph (a) of subsection 2, acceptable thresholds for the completeness and content of each element of historical data submitted by a data submitter; and

(b) For use in each quality audit conducted pursuant to paragraph (b) of subsection 2, a threshold for the reasonableness of the historical data, which may be expressed as a rate or a range.

5. When prescribing thresholds pursuant to subsection 4, the administrator shall initially assume that the acceptable threshold for each element is 100 percent but may establish a lower threshold upon determining that a threshold of 100 percent would be inappropriate for the element.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.838 Request for variance from validation of data. (NRS 439B.875)

1. A data submitter may request a variance from the validation of the data required by NAC 439B.836 to allow the collection of historical data to proceed while the data submitter adds missing elements of data or makes other improvements to its data.

2. A request for a variance made pursuant to this section must:

(a) Be made through the portal for the collection of historical data for the all-payer claims database which is managed by the administrator; and

(b) Clearly identify:

(1) The nature of the issue or issues affecting the historical data;

(2) A plan for correcting the issues, if applicable; and

(3) The date by which the data submitter anticipates compliance with requirements for the submission of historical data.

3. The administrator shall:

(a) Review a request for a variance which satisfies the requirements of subsection 2; and

(b) Approve or deny the request not later than 5 days after the date on which the request was submitted.

4. A variance granted pursuant to this section is valid for a period of time specified by the administrator, not to exceed 1 year.

5. If the administrator denies a request for a variance:

(a) The data submitter that submitted the request shall comply with all applicable requirements to submit historical data to the all-payer claims database; and

(b) Neither the data submitter nor an entity on whose behalf the data submitter was required to submit historical data to the all-payer claims database is entitled to a hearing on the denial. The provisions of this paragraph do not affect the right of any person or entity to a hearing pursuant to NAC 439B.844 on a decision to impose an administrative penalty for any attendant failure to comply with the provisions of NRS 439B.800 to 439B.875, inclusive, and NAC 439B.800 to 439B.844, inclusive.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.840 Request for extension of time to submit historical data. (NRS 439B.875)

1. A data submitter may request an extension of time to submit historical data to the all-payer claims database for a period of time for which the data submitter is unable to comply with the deadline prescribed by NAC 439B.830.

2. A request for an extension made pursuant to this section must be submitted to the Office and include:

(a) A detailed explanation of the reason the data submitter is unable to comply with the requirement to submit historical data to the all-payer claims database by the deadline prescribed by NAC 439B.830 for the submission of historical data to be accepted for that calendar quarter; and

(b) The period of time for which the data submitter is requesting an extension, not to exceed 1 calendar quarter.

3. Except as otherwise provided in this subsection, a request for an extension made pursuant to this section must be submitted to the Office not less than 30 calendar days before the first deadline to submit historical data to the all-payer claims database to which the extension would apply. If a data submitter is unable to submit a request for an extension to the Office on or before that date, the data submitter must notify the Office in writing as soon as the data submitter determines that an extension is necessary.

4. Upon receipt of a request for an extension submitted pursuant to this section not less than 30 calendar days before the first deadline to submit historical data to the all-payer claims database to which the extension would apply, the Office will suspend the requirement for the data submitter to submit historical data to the all-payer claims database while the Office determines whether to approve or deny the request. The Office may refuse to suspend that requirement if the request is submitted after that date.

5. Not later than 15 days after receipt of a request for an extension submitted pursuant to this section, the Office will issue a written determination to the data submitter notifying the data submitter whether the Office has approved or denied the request.

6. If the Office grants an extension, the written determination issued pursuant to subsection 5 must specify the period of time for which the extension has been granted.

7. If the Office denies a request for an extension made pursuant to this section:

(a) The data submitter that submitted the request shall comply with all applicable requirements to submit historical data to the all-payer claims database. If the denial is issued after the first deadline to submit historical data to the all-payer claims database to which the requested extension would have applied, the data submitter shall comply with all applicable requirements to submit historical data to the all-payer claims database within 15 calendar days after the date on which the written determination of denial was issued.

(b) Neither the data submitter nor any entity on whose behalf the data submitter was required to submit historical data to the all-payer claims database is entitled to a hearing on the denial. The provisions of this paragraph do not affect the right of any person or entity to a hearing pursuant to NAC 439B.844 on a decision to impose an administrative penalty for any attendant failure to comply with the provisions of NRS 439B.800 to 439B.875, inclusive, and NAC 439B.800 to 439B.844, inclusive.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

NAC 439B.842 Notification of and addressing errors in previously accepted historical data. (NRS 439B.875)

1. If the administrator determines that historical data which has previously been accepted contains an error that was not initially identified, the administrator shall notify the data submitter.

2. A data submitter that is notified of an error pursuant to subsection 1 shall address the error identified by the administrator by either:

(a) Providing an explanation and, as necessary, documentation, to the administrator to demonstrate that the historical data is correct as initially submitted; or

(b) Correcting the error and resubmitting the historical data not later than 60 calendar days after the date on which the administrator notified the data submitter of the error.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)

Administrative Penalties

NAC 439B.844 Amount; imputation of violation to certain entities; notice; hearing. (NRS 439B.875)

1. The Office may impose on a person or entity an administrative penalty for a violation of the provisions of NRS 439B.800 to 439B.875, inclusive, and NAC 439B.800 to 439B.844, inclusive, as follows:

(a) For the first violation within a 3-year period, an administrative penalty not to exceed $2,500 for each day the person or entity remains in violation.

(b) For the second and each subsequent violation within a 3-year period, an administrative penalty not to exceed $5,000 for each day the person or entity remains in violation.

2. The Office may impute a violation of the provisions of NRS 439B.800 to 439B.875, inclusive, and NAC 439B.800 to 439B.844, inclusive, by a data submitter to any entity on whose behalf the data submitter is required to submit historical data to the extent that the violation results in a violation of those provisions by that entity.

3. Upon deciding to impose an administrative penalty, the Office will provide written notice to the person or entity who is alleged to have committed the violation. The written notice must contain, without limitation:

(a) The determination of the Office, including, without limitation, each provision of law and regulatory provision which the person or entity is alleged to have violated; and

(b) Notification of the provisions of subsection 4.

4. Not later than 90 days after receiving notice of a decision to impose an administrative penalty pursuant to subsection 3, a person or entity may request a hearing by certified mail. If the Office receives a request for an administrative hearing that complies with the requirements of this subsection, the Office will:

(a) Appoint a hearing officer to conduct the hearing; and

(b) Notify the person or entity who requested the administrative hearing of the date, time, place and nature of the hearing.

5. The decision of a hearing officer appointed pursuant to subsection 4 must:

(a) Be in writing; and

(b) Detail the findings of the hearing officer and the support for those findings.

6. A decision by a hearing officer in an administrative hearing held pursuant to this section is a final decision for the purposes of judicial review.

(Added to NAC by Dep’t of Health & Human Services by R104-23, eff. 11-15-2024)