NRS: CHAPTER 695D - PLANS FOR DENTAL CARE

[Rev. 6/29/2024 5:02:41 PM--2023]

CHAPTER 695D - PLANS FOR DENTAL CARE

NRS 695D.010 Definitions.

NRS 695D.012 “Administrator” defined.

NRS 695D.020 “Commissioner” defined.

NRS 695D.030 “Dental care” defined.

NRS 695D.040 “Dentist” defined.

NRS 695D.050 “Member” defined.

NRS 695D.060 “Organization for dental care” defined.

NRS 695D.070 “Plan for dental care” defined.

NRS 695D.080 “Policy” defined.

NRS 695D.090 Applicability of title to organizations for dental care; applicability of chapter.

NRS 695D.095 Applicability of chapter and certain other provisions to organizations for dental care.

NRS 695D.100 Regulations.

NRS 695D.102 Summary of coverage: Contents of disclosure; approval by Commissioner; regulations.

NRS 695D.104 Summary of coverage: Copy required to be provided to group policyholder before issuance of policy; organization prohibited from offering plan unless disclosure approved by Commissioner.

NRS 695D.110 Certificate of authority: Required for establishing, operating, acting as administrator of, selling or offering to sell plan for dental care.

NRS 695D.120 Certificate of authority: Application.

NRS 695D.130 Certificate of authority: Issuance; fees.

NRS 695D.140 Certificate of authority: Notice of change of information; application for amendment; fee; approval.

NRS 695D.150 Certificate of authority: Expiration; renewal; fees.

NRS 695D.153 Capital account: Minimum amount; requirements.

NRS 695D.157 Hazardous financial condition: Regulations; determination; powers of Commissioner.

NRS 695D.160 Composition of board of directors for organization for dental care that is corporation.

NRS 695D.170 Bond or deposit: Required; amount; creation of Fund for Bonds of Organizations for Dental Care; judgment as lien; disposition upon dissolution, liquidation or other termination of organization.

NRS 695D.180 Requirements concerning bond.

NRS 695D.190 Certain persons in organization for dental care in fiduciary relationship to members; dentist subject to disciplinary action for breaches of fiduciary or contractual obligations.

NRS 695D.200 Policy: Review by prospective members at meeting; provision of copy to members; approval by Commissioner; form and contents; notice of change.

NRS 695D.203 Group plan issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability to self-insured employer.

NRS 695D.205 Copayments and deductibles: Reasonableness; approval of Commissioner; regulations.

NRS 695D.210 Policy covering dependent of member required to include coverage for member’s newly born and adopted children and children placed with member for adoption to same extent as other dependents.

NRS 695D.215 Claims: Approval or denial; request for additional information; payment; interest on unpaid claim.

NRS 695D.2153 Claims: Organization for dental care or administrator prohibited from denying claim for which prior authorization has been granted; exceptions.

NRS 695D.2157 Recovery of overpayments: Notice; procedures for challenging attempted recovery; limitation of period for recovery; exception.

NRS 695D.216 Required provision concerning coverage for services provided through telehealth to same extent as though provided in person or by other means; required provision concerning reimbursement for certain services provided through telehealth in same amount as though provided in person or by other means; prohibited acts.

NRS 695D.219 Organization for dental care prohibited from denying coverage solely because applicant or member was intoxicated or under the influence of controlled substance; exceptions.

NRS 695D.220 Licensing of agents.

NRS 695D.225 Contracts between organization for dental care and dentist: Modification; submission of schedule of payments upon request; exceptions.

NRS 695D.227 Prohibitions related to setting of fees by plan or organization for dental care other than covered services to members.

NRS 695D.230 Advertising or materials used to enroll or solicit members: Approval of Commissioner; penalties.

NRS 695D.240 Limitation on use of charges or premiums for marketing and administrative expenses; regulations.

NRS 695D.250 Reserves: Maintenance; exception; held in fiduciary capacity; deposit; penalty for diversion or appropriation; regulations.

NRS 695D.260 Annual report; financial statement; quarterly statement; administrative penalty for failure to file timely report or statement; extension of time; payment of premium tax and filing fee.

NRS 695D.270 Examination by Commissioner.

NRS 695D.280 Rehabilitation, liquidation or conservation: Conduct.

NRS 695D.290 Trade practices and frauds: Applicability of provisions to organizations for dental care.

NRS 695D.300 Disciplinary action: Grounds; penalties.

NRS 695D.310 Disciplinary or other action: Notice; hearing; order.

_________

NRS 695D.010 Definitions. As used in this chapter, unless the context otherwise requires, the words and terms defined in NRS 695D.012 to 695D.080, inclusive, have the meanings ascribed to them in those sections.

(Added to NRS by 1983, 2021; A 2021, 3529)

NRS 695D.012 “Administrator” defined. “Administrator” has the meaning ascribed to it in NRS 683A.025.

(Added to NRS by 2021, 3527)

NRS 695D.020 “Commissioner” defined. “Commissioner” means the Commissioner of Insurance.

(Added to NRS by 1983, 2021)

NRS 695D.030 “Dental care” defined. “Dental care” means the services ordinarily provided by dentists and includes appliances, drugs, medicines, supplies, prosthetic appliances, orthodontic appliances, and metal, ceramic or other restorations customarily used or provided by a dentist.

(Added to NRS by 1983, 2021)

NRS 695D.040 “Dentist” defined. “Dentist” includes a dental hygienist and an expanded function dental assistant.

(Added to NRS by 1983, 2021; A 2023, 3438)

NRS 695D.050 “Member” defined. “Member” includes the person enrolled in a plan for dental care and the person’s dependents who may also be enrolled in the plan.

(Added to NRS by 1983, 2021)

NRS 695D.060 “Organization for dental care” defined. “Organization for dental care” means any person who agrees to provide coverage for dental care through one or more plans for dental care.

(Added to NRS by 1983, 2021)

NRS 695D.070 “Plan for dental care” defined. “Plan for dental care” means any agreement in which a person agrees to provide or arrange for dental care or pay for or reimburse any part of the cost of that care and the member agrees to prepay, make periodic payments or pay through insurance for that care.

(Added to NRS by 1983, 2021; A 1985, 2098)

NRS 695D.080 “Policy” defined. “Policy” means the document given to a member which describes the dental care to which the member is entitled under a plan for dental care and the obligations of the member to the organization for dental care.

(Added to NRS by 1983, 2021)

NRS 695D.090 Applicability of title to organizations for dental care; applicability of chapter.

1. Except as otherwise specifically provided in this chapter or elsewhere in this title, the provisions of this title other than this chapter do not apply to organizations for dental care. This exemption does not apply to any insurer authorized pursuant to any other provision of this title except with respect to those activities authorized and regulated by this chapter.

2. The provisions of this chapter do not apply to:

(a) Any person, corporation or organization which must be authorized by the Commissioner to transact the business of insurance pursuant to chapter 680A, 695B or 695C of NRS.

(b) Any plan established to provide health and welfare benefits to employees pursuant to a collective bargaining agreement.

(Added to NRS by 1983, 2021)

NRS 695D.095 Applicability of chapter and certain other provisions to organizations for dental care.

1. An organization for dental care is subject to the provisions of this chapter and to the provisions set forth in this section, to the extent reasonably applicable. Organizations for dental care are subject to the provisions of NRS 449.465, 679B.700, subsections 7 and 8 of NRS 680A.270, subsections 2, 4, 17, 18 and 30 of NRS 680B.010, NRS 680B.020 to 680B.060, inclusive, chapters 681B and 686A of NRS, NRS 686B.010 to 686B.175, inclusive, and chapters 687B, 692C and 695G of NRS.

2. For the purposes of this section and the provisions set forth in subsection 1, an organization for dental care is included in the meaning of the term “insurer.”

(Added to NRS by 1987, 470; A 2017, 2397; 2021, 2995; 2023, 2643)

NRS 695D.100 Regulations. The Commissioner may adopt any regulations necessary to carry out the provisions of this chapter.

(Added to NRS by 1983, 2022)

NRS 695D.102 Summary of coverage: Contents of disclosure; approval by Commissioner; regulations.

1. The Commissioner shall adopt regulations which require an organization for dental care to file with the Commissioner, for approval by the Commissioner, a disclosure summarizing the coverage provided by each plan for dental care offered by the organization for dental care. The disclosure must include:

(a) Any significant exception, reduction or limitation that applies to the plan; and

(b) Any other information,

Ê that the Commissioner finds necessary to provide for full and fair disclosure of the provisions of the plan.

2. The disclosure must be written in language which is easily understood and must include a statement that the disclosure is a summary of the policy only, and that the policy itself should be read to determine the governing contractual provisions.

3. The Commissioner shall not approve any proposed disclosure submitted to the Commissioner pursuant to this section which does not comply with the requirements of this section and the applicable regulations.

(Added to NRS by 1989, 1254)

NRS 695D.104 Summary of coverage: Copy required to be provided to group policyholder before issuance of policy; organization prohibited from offering plan unless disclosure approved by Commissioner. An organization for dental care shall provide to the group policyholder to whom it offers a plan for dental care a copy of the disclosure approved for that plan pursuant to NRS 695D.102 before the policy is issued. An organization for dental care shall not offer a plan for dental care unless the disclosure for that plan has been approved by the Commissioner.

(Added to NRS by 1989, 1254)

NRS 695D.110 Certificate of authority: Required for establishing, operating, acting as administrator of, selling or offering to sell plan for dental care. No person may establish or operate a plan for dental care, act as an administrator of such a plan or sell or offer to sell such a plan without first obtaining a certificate of authority from the Commissioner.

(Added to NRS by 1983, 2022)

NRS 695D.120 Certificate of authority: Application. Each application for a certificate of authority must be filed with the Commissioner on a form prescribed by the Commissioner, must be verified by an officer or authorized representative of the organization for dental care and must include:

1. A copy of any organizational document for the organization and all amendments to that document.

2. A copy of any bylaws, rules or regulations governing the internal affairs of the organization.

3. A list of the names, addresses and official positions of the persons responsible for operating the organization, including the members of the board of directors, board of trustees, executive committee, principal officers or partners.

4. A copy of the contracts made or proposed to be made between the applicant and those persons listed in subsection 3 and the dentists.

5. A statement describing the applicant’s plan for dental care, its facilities and personnel.

6. A copy of the policy to be issued to its members.

7. A copy of any contract for groups to be issued to employers, unions, trustees or other organizations.

8. Certified financial statements showing the applicant’s assets, liabilities and sources of support. A copy of the applicant’s most recent certified financial statement satisfies this requirement unless the Commissioner requests additional information from the applicant.

9. A description of the method to be used to market the plan for dental care, including a financial statement, a projection for the initial 5 years of operation of the plan and a statement of the sources of capital for the organization.

10. A power of attorney executed by the applicant or its officers, which appoints the Commissioner as the attorney for the applicant upon whom service of process may be made in this State.

11. A statement describing the geographic area or areas to be served by the applicant.

12. A statement indicating that all the dentists for the plan are licensed pursuant to chapter 631 of NRS.

13. Any other information requested by the Commissioner.

(Added to NRS by 1983, 2022)

NRS 695D.130 Certificate of authority: Issuance; fees. The Commissioner shall issue a certificate of authority to an organization for dental care after the organization has paid an application fee of $2,450 and, in addition to any other fee or charge, all applicable fees required pursuant to NRS 680C.110, and the Commissioner is satisfied that:

1. The persons responsible for operating the organization are competent, trustworthy, have not been convicted of a felony and have good reputations.

2. The plan for dental care includes care which is appropriate for the plan and the plan is appropriate for providing that care.

3. The organization is financially responsible and may reasonably be expected to meet its obligations to its members. To determine financial responsibility the Commissioner may consider:

(a) The organization’s arrangements for dental care and the schedule of charges to be used;

(b) The agreements with an insurer, government or any other organizations for ensuring payment for the dental care;

(d) The agreements with the dentists providing dental care to the organization’s members.

4. The appropriate deposits or bonds have been filed with the Commissioner by the organization and its officers.

(Added to NRS by 1983, 2023; A 1991, 1634; 2009, 1819)

NRS 695D.140 Certificate of authority: Notice of change of information; application for amendment; fee; approval.

1. Except as otherwise provided in subsection 2, every organization issued a certificate of authority by the Commissioner shall notify the Commissioner of any change in the information provided to obtain its certificate of authority within 10 days after the change.

2. Every such organization that wishes to make a change in the geographic areas which it serves, or to make any other material modification of the operations described in the information required by NRS 695D.120, shall file with the Commissioner an application for the amendment of the certificate of authority and pay to the Commissioner an application fee of $100. If the Commissioner does not disapprove the application within 30 days after filing, it shall be deemed approved.

(Added to NRS by 1983, 2023; A 1991, 2205)

NRS 695D.150 Certificate of authority: Expiration; renewal; fees. A certificate of authority expires at midnight on March 1 following the date it was issued or previously renewed. The Commissioner shall renew the certificate of any organization for dental care which:

1. Continues to comply with the provisions of this chapter; and

2. Pays the fee for renewal of $2,450 and, in addition to any other fee or charge, all applicable fees required pursuant to NRS 680C.110.

(Added to NRS by 1983, 2023; A 1987, 470; 1991, 1635; 1993, 614; 2009, 1819)

NRS 695D.153 Capital account: Minimum amount; requirements.

1. Each organization for dental care which receives a certificate of authority shall maintain a capital account with a net worth of not less than $500,000 unless a lesser amount is permitted in writing by the Commissioner.

2. An organization for dental care which has been issued a certificate of authority pursuant to this chapter shall maintain a capital account with a net worth in an amount which is not less than the greater of:

(a) The amount of risk-based capital required by regulations adopted by the Commissioner pursuant to NRS 681B.550; or

(b) The following applicable amount, according to the number of members in the organization:

Number of members Net worth

Less than 2,500............................................................................................... $50,000

At least 2,500 but not more than 5,000......................................................... 75,000

More than 5,000.............................................................................................. 125,000

3. The account must not be obligated for any accrued liabilities and must consist of cash, securities or a combination thereof which is acceptable to the Commissioner.

(Added to NRS by 2017, 2397; A 2019, 1720)

NRS 695D.157 Hazardous financial condition: Regulations; determination; powers of Commissioner.

1. The Commissioner may adopt regulations to define when an organization for dental care is considered to be in a hazardous financial condition and to set forth the standards to be considered by the Commissioner in determining whether the continued operation of an organization for dental care transacting business in this State may be considered to be hazardous to its members or creditors or to the general public.

2. If the Commissioner determines after a hearing that any organization for dental care is in a hazardous financial condition, the Commissioner may, instead of suspending or revoking the certificate of authority of the organization, limit the certificate of authority as the Commissioner deems reasonably necessary to correct, eliminate or remedy any conduct, condition or ground that is deemed to be a cause of the hazardous financial condition.

3. An order or decision of the Commissioner under this section is subject to review in accordance with NRS 679B.310 to 679B.370, inclusive, at the request of any party to the proceedings whose interests are substantially affected.

(Added to NRS by 2017, 2397)

NRS 695D.160 Composition of board of directors for organization for dental care that is corporation. If an organization for dental care is a corporation, its board of directors must include:

1. Dentists who have contracted with the organization to provide dental care to its members; and

2. Members of the plan for dental care, who must comprise at least one-third of the membership of the board by the end of its first year of operation.

(Added to NRS by 1983, 2023)

1. Except as otherwise provided in this section, before a certificate of authority may be issued to an organization for dental care:

(a) The officers responsible for operating the organization must file with the Commissioner a collective fidelity bond for $1,000,000; and

(b) The organization must file with the Commissioner a surety bond in the sum of $500,000 or deposit with the Commissioner cash or securities acceptable to the Commissioner in the sum of $500,000,

Ê to guarantee the organization’s performance pursuant to this chapter.

2. If the bond is furnished in:

(a) Cash, the Commissioner shall deposit the money in the State Treasury for credit to the Fund for Bonds of Organizations for Dental Care which is hereby created as a trust fund.

(b) Negotiable securities, the principal must be placed without restriction at the disposal of the Commissioner, but any income must inure to the benefit of the organization.

3. The Commissioner may reduce the required amount of the organization’s surety bond or deposit:

(a) To $125,000, if the obligations assumed by the organization under the plan can be satisfied for less than $125,000.

(b) To any amount if the organization demonstrates that it has commitments of money from federal, state or municipal governments or their political subdivisions or other comparable resources which are sufficient to ensure the ability of the organization to satisfy its obligations.

4. The Commissioner may increase the required amount of the organization’s surety bond or deposit to any amount the Commissioner determines to be appropriate pursuant to subsection 5 if the Commissioner determines that the current level of the surety bond or deposit is insufficient to provide protection to the members in the event of:

(a) Insolvency; or

(b) A determination by the Commissioner that the organization is in a hazardous financial condition.

5. When determining the appropriate amount of an increase pursuant to subsection 4, the Commissioner must base his or her determination on the type, volume and nature of premiums written and premiums assumed by the organization.

6. The amount of the organization’s surety bond or deposit required pursuant to this section:

(a) Is in addition to any reserve required by this chapter and any reserve established by the organization according to good business and accounting practices for incurred but unreported claims and other similar claims;

(b) May increase the amount of net worth required pursuant to this chapter; and

7. Any final judgment against the organization which is unpaid is a lien on the surety bond or deposit and is subject to execution 30 days after entry of the judgment. Any surety bond or deposit which is reduced by this lien must be increased by the organization to the amount required by this section within 90 days after the judgment is paid.

8. If an organization is dissolved, liquidated or otherwise terminated:

(a) That amount of the surety bond or deposit which is necessary to satisfy the outstanding obligations of the organization may not be withdrawn for at least 3 years after the certificate of authority has been terminated.

(b) Any balance remaining after money has been withheld to pay the organization’s debts and liens must be paid to the organization by the Commissioner no later than 90 days after the certificate of authority has been terminated.

(Added to NRS by 1983, 2023; A 2017, 2398)

NRS 695D.180 Requirements concerning bond. An organization for dental care or its officers under this chapter shall file a bond with the Commissioner. The bond must comply with NRS 679B.175.

(Added to NRS by 1983, 2024; A 2021, 2995)

NRS 695D.190 Certain persons in organization for dental care in fiduciary relationship to members; dentist subject to disciplinary action for breaches of fiduciary or contractual obligations. Any director, officer, partner or employee of an organization for dental care who receives, collects, disburses or invests money in connection with the activities of that organization is responsible for that money and has a fiduciary duty and relationship to the members of the organization. Any dentist who breaches this fiduciary duty or fails to satisfy his or her contractual obligation to the organization or the members thereof is subject to disciplinary action pursuant to NRS 631.350.

(Added to NRS by 1983, 2024)

NRS 695D.200 Policy: Review by prospective members at meeting; provision of copy to members; approval by Commissioner; form and contents; notice of change.

1. An organization for dental care shall:

(a) Hold a meeting for all prospective members to review fully the policy being offered and describe the coverage under the plan for dental care before any contract is executed between the parties.

(b) Provide to each member a copy of the policy describing his or her coverage under the plan for dental care.

2. The Commissioner must approve every policy and amendment to it before they are distributed to the members or any other person. If the Commissioner does not disapprove the policy within 30 days after it is filed with the Commissioner, it shall be deemed to be approved. If the Commissioner disapproves a policy, the Commissioner shall notify the organization of the reasons for disapproval. The Commissioner shall grant a hearing on any disapproval of a policy or amendment within 15 days after the organization requests, in writing, a hearing on the matter.

3. A policy must contain a clear and complete statement of the contract between the parties or a summary of the contract which describes:

(a) The dental care and other benefits to which the member is entitled;

(b) Any limitations on the care to be provided, including any deductibles or copayments to be paid by a member;

(d) The member’s obligations for payment under the plan for dental care.

4. The organization must give notice to the Commissioner and every member 30 days before any change is made in the member’s policy.

(Added to NRS by 1983, 2025)

NRS 695D.203 Group plan issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability to self-insured employer.

1. A group plan for dental care issued by an organization for dental care to replace any discontinued policy or coverage for dental care must:

(a) Provide coverage for all persons who were covered under the previous policy or coverage on the date it was discontinued; and

(b) Except as otherwise provided in subsection 2, provide benefits which are at least as extensive as the benefits provided by the previous policy or coverage, except that benefits may be reduced or excluded to the extent that such a reduction or exclusion was permissible under the terms of the previous policy or coverage,

Ê if that plan is issued within 60 days after the date on which the previous policy or coverage was discontinued.

2. If an employer obtains a replacement plan pursuant to subsection 1 to cover the employees of the employer, any benefits provided by the previous policy or coverage may be reduced if notice of the reduction is given to the employees pursuant to NRS 608.1577.

3. Any organization for dental care which issues a replacement plan pursuant to subsection 1 may submit a written request to the insurer which provided the previous policy or coverage for a statement of benefits which were provided under that policy or coverage. Upon receiving such a request, the insurer shall give a written statement to the organization indicating what benefits were provided and what exclusions or reductions were in effect under the previous policy or coverage.

4. The provisions of this section apply to a self-insured employer who provides benefits to the employees of the self-insured employer for dental care and replaces those benefits with a group plan for dental care.

(Added to NRS by 1987, 851)

NRS 695D.205 Copayments and deductibles: Reasonableness; approval of Commissioner; regulations.

1. Each copayment and deductible required to be paid by a member must be reasonable and reasonably related to the cost of the particular service.

2. Every organization for dental care shall submit to the Commissioner for approval any proposal for copayment or deductible before it is imposed on the members. The Commissioner shall approve or disapprove the proposal within 30 days after it is submitted to the Commissioner. If the Commissioner disapproves a copayment or deductible, the Commissioner shall notify the organization of the reasons for disapproval. The Commissioner shall grant a hearing on any such disapproval within 15 days after the organization requests, in writing, a hearing on the matter.

3. The Commissioner may adopt regulations to define:

(a) “Reasonable” as it relates to copayments and deductibles; and

(b) A “reasonable relationship” between the cost of particular services and the amount of related copayments and deductibles.

(Added to NRS by 1987, 1783)

1. Any policy which provides coverage for a dependent of a member must provide that benefits for children are payable for a member’s newly born child, adopted child or child placed with the member for the purpose of adoption to the same extent that the coverage applies to other dependents.

2. The policy may require that to have coverage for the newly born child, adopted child or child placed for adoption continued beyond 31 days after the child’s birth, adoption or placement, the member must notify the organization for dental care within 31 days after the birth, adoption or placement.

3. For covered services provided to the child, the organization for dental care shall reimburse noncontracted providers of health care to an amount equal to the average amount of payment for which the organization has agreements, contracts or arrangements for those covered services.

(Added to NRS by 1983, 2025; A 1989, 742)

NRS 695D.215 Claims: Approval or denial; request for additional information; payment; interest on unpaid claim.

1. Except as otherwise provided in subsection 2, an organization for dental care shall approve or deny a claim relating to a plan for dental care within 30 days after the organization for dental care receives the claim. If the claim is approved, the organization for dental care shall pay the claim within 30 days after it is approved. If the approved claim is not paid within that period, the organization for dental care shall pay interest on the claim at the rate of interest established pursuant to NRS 99.040. The interest must be calculated from the date the payment is due until the claim is paid.

2. If the organization for dental care requires additional information to determine whether to approve or deny the claim, it shall notify the claimant of its request for the additional information within 20 days after it receives the claim. The organization for dental care shall notify the provider of dental care of the reason for the delay in approving or denying the claim. The organization for dental care shall approve or deny the claim within 30 days after receiving the additional information. If the claim is approved, the organization for dental care shall pay the claim within 30 days after it receives the additional information. If the approved claim is not paid within that period, the organization for dental care shall pay interest on the claim in the manner prescribed in subsection 1.

(Added to NRS by 1991, 1332)

NRS 695D.2153 Claims: Organization for dental care or administrator prohibited from denying claim for which prior authorization has been granted; exceptions.

1. An organization for dental care or an administrator of a dental plan shall not refuse to pay a claim for dental care for which the organization for dental care or administrator, as applicable, has granted prior authorization unless:

(a) A limitation on coverage provided under the applicable plan for dental care, including, without limitation, a limitation on total costs or frequency of services:

(1) Did not apply at the time the prior authorization was granted; and

(2) Applied at the time of the provision of the dental care for which the prior authorization was granted because additional covered dental care was provided to the member after the prior authorization was granted and before the provision of the dental care for which prior authorization was granted;

(b) The documentation provided by the person submitting the claim clearly fails to support the claim for which prior authorization was originally granted;

(c) After the prior authorization was granted, additional dental care was provided to the member or the condition of the member otherwise changed such that:

(1) The dental care for which prior authorization was granted is no longer medically necessary; or

(2) The organization for dental care or administrator, as applicable, would be required to deny prior authorization under the terms and conditions of the applicable plan for dental care that were in effect at the time of the provision of the dental care for which prior authorization was granted;

(d) Another person or entity is responsible for the payment;

(e) The dentist has previously been paid for the procedures covered by the claim;

(f) The claim was fraudulent or the prior authorization was based, in whole or in part, on materially false information provided by the dentist or member or another person who is not affiliated with the organization for dental care or administrator, as applicable; or

(g) The member was not eligible to receive the dental care for which the claim was made on the date that the dental care was provided.

2. Any provision of a contract that conflicts with this section is against public policy, void and unenforceable.

3. As used in this section:

(a) “Medically necessary” means dental care that a prudent dentist would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that is necessary and:

(1) Provided in accordance with generally accepted standards of dental practice;

(2) Clinically appropriate with regard to type, frequency, extent, location and duration;

(3) Not primarily provided for the convenience of the patient or dentist;

(4) Required to improve a specific dental condition of a patient or to preserve the existing state of oral health of the patient; and

(5) The most clinically appropriate level of dental care that may be safely provided to the patient.

(b) “Prior authorization” means any communication issued by an organization for dental care or the administrator of a dental plan in response to a request by a dentist in the form prescribed by the organization for dental care or administrator, as applicable, which indicates that specific dental care provided to a patient is:

(1) Covered under the plan for dental care issued to the member; and

(2) Reimbursable in a specific amount, subject to applicable deductibles, copayments and coinsurance.

(Added to NRS by 2021, 3528)

NRS 695D.2157 Recovery of overpayments: Notice; procedures for challenging attempted recovery; limitation of period for recovery; exception.

1. An organization for dental care or an administrator who recovers overpayments under a plan for dental care shall provide written notice to a dentist of any attempt to recover an overpayment, other than a duplicate payment. The notice must include, without limitation:

(a) A description of the error that justifies the recovery; and

(b) The date on which the dental care for which the overpayment was made was provided and the name of the member to whom the dental care was provided.

2. An organization for dental care or an administrator who recovers overpayments under a plan for dental care shall establish written procedures by which a dentist may challenge an attempt to recover an overpayment. Those procedures must include, without limitation, procedures for sharing information concerning a disputed claim with the dentist.

3. Except as otherwise provided in this subsection, an organization for dental care or an administrator who recovers overpayments under a plan for dental care shall not attempt to recover an overpayment more than 12 months after the date of the overpayment. This subsection does not apply to an attempt to recover an overpayment that is:

(a) Based on a reasonable belief that the overpayment involved fraud, abuse or other intentional misconduct; or

(b) Initiated by or at the request of a self-insured employer.

4. Any provision of a contract that conflicts with this section is against public policy, void and unenforceable.

(Added to NRS by 2021, 3528)

1. A plan for dental care must include coverage for services provided to a member through telehealth to the same extent as though provided in person or by other means.

2. A plan for dental care must provide reimbursement for services described in subsection 1 in the same amount as though provided in person or by other means if the services:

(a) Are received at an originating site described in 42 U.S.C. § 1395m(m)(4)(C) or furnished by a federally-qualified health center or a rural health clinic; and

(b) Are not provided through audio-only interaction.

3. An organization for dental care shall not:

(a) Require a member to establish a relationship in person with a provider of health care or provide any additional consent to or reason for obtaining services through telehealth as a condition to providing the coverage described in subsection 1 or the reimbursement described in subsection 2;

(b) Require a provider of health care to demonstrate that it is necessary to provide services to a member through telehealth or receive any additional type of certification or license to provide services through telehealth as a condition to providing the coverage described in subsection 1 or the reimbursement described in subsection 2;

(1) The distant site from which a provider of health care provides services through telehealth or the originating site at which a member receives services through telehealth; or

(2) The technology used to provide the services:

(d) Require covered services to be provided through telehealth as a condition to providing coverage for such services; or

(e) Categorize a service provided through telehealth differently for purposes relating to coverage or reimbursement than if the service had been provided in person or through other means.

4. A plan for dental care must not require a member to obtain prior authorization for any service provided through telehealth that is not required for the service when provided in person. A plan for dental care may require prior authorization for a service provided through telehealth if such prior authorization would be required if the service were provided in person or by other means.

5. The provisions of this section do not require an organization for dental care to:

(a) Ensure that covered services are available to a member through telehealth at a particular originating site;

(b) Provide coverage for a service that is not a covered service or that is not provided by a covered provider of health care; or

(c) Enter into a contract with any provider of health care or cover any service if the organization for dental care is not otherwise required by law to do so.

6. A plan for dental care subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, has the legal effect of including the coverage required by this section, and any provision of the plan or the renewal which is in conflict with this section is void.

7. As used in this section:

(a) “Distant site” has the meaning ascribed to it in NRS 629.515.

(b) “Federally-qualified health center” has the meaning ascribed to it in 42 U.S.C. § 1396d(l)(2)(B).

(d) “Provider of health care” has the meaning ascribed to it in NRS 439.820.

(e) “Rural health clinic” has the meaning ascribed to it in 42 U.S.C. § 1395x(aa)(2).

(f) “Telehealth” has the meaning ascribed to it in NRS 629.515.

(Added to NRS by 2015, 645; A 2021, 3040, 3041; 2023, 233, 237)

NRS 695D.217 Organization for dental care prohibited from denying coverage solely because claim involves act that constitutes domestic violence or applicant or insured was victim of domestic violence. An organization for dental care shall not deny a claim, refuse to issue a policy or cancel a policy solely because the claim involves an act that constitutes domestic violence pursuant to NRS 33.018, or because the person applying for or covered by the policy was the victim of such an act of domestic violence, regardless of whether the insured or applicant contributed to any loss or injury.

(Added to NRS by 1997, 1097)

NRS 695D.219 Organization for dental care prohibited from denying coverage solely because applicant or member was intoxicated or under the influence of controlled substance; exceptions.

1. Except as otherwise provided in subsection 2, an organization for dental care shall not:

(a) Deny a claim under a plan for dental care solely because the claim involves an injury sustained by a member as a consequence of being intoxicated or under the influence of a controlled substance.

(b) Cancel participation under a plan for dental care solely because a member has made a claim involving an injury sustained by the member as a consequence of being intoxicated or under the influence of a controlled substance.

(c) Refuse participation under a plan for dental care to an eligible applicant solely because the applicant has made a claim involving an injury sustained by the applicant as a consequence of being intoxicated or under the influence of a controlled substance.

2. The provisions of this section do not prohibit an organization for dental care from enforcing a provision included in a plan for dental care to:

(a) Deny a claim which involves an injury to which a contributing cause was the insured’s commission of or attempt to commit a felony;

(b) Cancel participation under a plan for dental care solely because of such a claim; or

(Added to NRS by 2005, 2346)

NRS 695D.220 Licensing of agents.

1. The provisions of chapter 683A of NRS apply to the licensing of agents for an organization for dental care.

2. As used in this section, “agent” means any person who is associated, directly or indirectly, with the organization and engages in soliciting or enrolling members.

(Added to NRS by 1983, 2027)

NRS 695D.225 Contracts between organization for dental care and dentist: Modification; submission of schedule of payments upon request; exceptions.

1. Except as otherwise provided in NRS 695D.227, a contract between an organization for dental care and a dentist may be modified:

(a) At any time pursuant to a written agreement executed by both parties.

(b) Except as otherwise provided in this paragraph, by the organization for dental care upon giving to the dentist 45 days’ written notice of the modification of the organization for dental care’s schedule of payments, including any changes to the fee schedule applicable to the dentist’s practice. If the dentist fails to object in writing to the modification within the 45-day period, the modification becomes effective at the end of that period. If the dentist objects in writing to the modification within the 45-day period, the modification must not become effective unless agreed to by both parties as described in paragraph (a).

2. If an organization for dental care contracts with a dentist, the organization for dental care shall:

(a) If requested by the dentist at the time the contract is made, submit to the dentist the schedule of payments applicable to the dentist; or

(b) If requested by the dentist at any other time, submit to the dentist the schedule of payments, including any changes to the fee schedule applicable to the dentist’s practice, specified in paragraph (a) within 7 days after receiving the request.

3. The provisions of this section do not apply to an organization for dental care that provides services to recipients of Medicaid under the State Plan for Medicaid or insurance pursuant to the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Health and Human Services. This subsection does not exempt an organization for dental care from any provision of this chapter for services provided pursuant to any other contract.

(Added to NRS by 2011, 2536; A 2013, 1240)

NRS 695D.227 Prohibitions related to setting of fees by plan or organization for dental care other than covered services to members.

1. No plan for dental care and no contract between an organization for dental care and a dentist may require, directly or indirectly, that the dentist provide dental care to a member at a fee set by or subject to the approval of the organization for dental care unless the dental care is a covered service.

2. An organization for dental care or any other person providing services as a third-party administrator shall not make available any dentists in its network of dentists to a plan for dental care that sets fees for any dental care except covered services.

3. As used in this section, “covered service” means dental care for which reimbursement is available under a member’s policy, or for which reimbursement would be available but for the application of a contractual limitation, including, without limitation, any deductible, copayment, coinsurance, waiting period, annual or lifetime maximum, frequency limitation, alternative benefit payment or any other limitation.

(Added to NRS by 2013, 1239)

NRS 695D.230 Advertising or materials used to enroll or solicit members: Approval of Commissioner; penalties.

1. Every organization for dental care must submit any advertising, or other materials to be used to enroll or solicit members, to the Commissioner for approval by the Commissioner before they are used by the organization.

2. If the Commissioner does not disapprove the advertising or other materials within 30 days after they are filed with the Commissioner, they shall be deemed to be approved. If the Commissioner disapproves any of the advertising or other materials because they are false, deceptive, or misleading, the Commissioner shall notify the organization of the reasons for disapproving them. The Commissioner shall grant a hearing on the matter within 15 days after the organization requests, in writing, a hearing on the matter.

3. If any advertising or other materials are circulated, issued, displayed or used in any manner to enroll or solicit members before they are approved by the Commissioner or after the Commissioner has disapproved them, the Commissioner may withdraw approval, if any, of the policy and plan for dental care proposed by the organization or take any other disciplinary action permitted by this chapter against the organization.

(Added to NRS by 1983, 2025)

NRS 695D.240 Limitation on use of charges or premiums for marketing and administrative expenses; regulations.

1. The organization for dental care shall use not more than 25 percent of its prepaid charges or premiums for marketing and administrative expenses, including all costs to solicit members or dentists.

2. The Commissioner may adopt regulations which define “marketing and administrative expenses” for the purposes of subsection 1.

(Added to NRS by 1983, 2026; A 1993, 2401)

NRS 695D.250 Reserves: Maintenance; exception; held in fiduciary capacity; deposit; penalty for diversion or appropriation; regulations.

1. An organization for dental care shall set aside a reserve equal to 3 percent of the premiums collected from its members up to a total of $500,000. This reserve is in addition to the bond or deposit filed with the Commissioner.

2. This section does not apply to organizations receiving money from federal, state or municipal governments or their political subdivisions or another comparable resource which have had their deposit or bond reduced by the Commissioner.

3. Every organization shall maintain the reserves required by NRS 681B.080, unless a larger amount is required by subsection 1 of this section.

4. The reserve required by subsection 1 is held by the organization in a fiduciary capacity. The organization must deposit the reserve in an interest-bearing trust account established in a bank, credit union, savings and loan association or savings bank in this state that is federally insured or insured by a private insurer approved pursuant to NRS 672.755. The account must be separate from all other accounts maintained by the organization.

5. Any person who diverts or appropriates reserves held in a fiduciary capacity pursuant to this section for the person’s own use is guilty of embezzlement.

6. The Commissioner may adopt reasonable regulations related to the adequacy of a reserve required by this section and the establishment and maintenance of a trust account pursuant to this section.

(Added to NRS by 1983, 2026; A 1993, 2401; 1999, 1554)

NRS 695D.260 Annual report; financial statement; quarterly statement; administrative penalty for failure to file timely report or statement; extension of time; payment of premium tax and filing fee.

1. Every organization for dental care shall file with the Commissioner on or before March 1 of each year a report covering its activities for the preceding calendar year. The report must be verified by at least two officers of the organization.

2. The report must be on a form prescribed by the Commissioner and must include:

(a) A financial statement of the organization, including its balance sheet and receipts and disbursements for the preceding calendar year.

(b) Any material changes in the information given in the previous report.

(c) The number of members enrolled in that year, the number of members whose coverage has been terminated in that year and the total number of members at the end of the year.

(d) The costs of all goods, services and dental care provided that year.

(e) Any other information relating to the plan for dental care requested by the Commissioner.

3. Every organization for dental care shall file with the Commissioner annually an audited financial statement in accordance with the provisions of subsection 1 of NRS 680A.265.

4. Every organization for dental care shall file with the Commissioner and the National Association of Insurance Commissioners a quarterly statement in the form most recently adopted by the National Association of Insurance Commissioners for that type of insurer. The quarterly statement must be:

(a) Prepared in accordance with the instructions which are applicable to that form, including, without limitation, the required date of submission for the form; and

(b) Filed by electronic means.

5. If an organization fails to file timely a report or financial statement required by this section, it shall pay an administrative penalty of $100 per day until the report or statement is filed, except that the total penalty must not exceed $3,000. The Attorney General shall recover the penalty in the name of the State of Nevada.

6. The Commissioner may grant a reasonable extension of time for filing any report or statement required by this section, if the request for an extension is submitted in writing and shows good cause.

7. The organization shall pay the Department of Taxation the annual tax, any penalty for nonpayment or delinquent payment of the tax imposed in chapter 680B of NRS, and a filing fee of $25 to the Commissioner, at the time the annual report is filed.

(Added to NRS by 1983, 2026; A 1987, 471; 1991, 2206; 1993, 1923; 1995, 1633, 2682; 2019, 1720)

NRS 695D.270 Examination by Commissioner.

1. The Commissioner shall, not less frequently than once every 3 years, conduct an examination of an organization for dental care pursuant to NRS 679B.250 to 679B.300, inclusive.

2. The Commissioner may examine any organization which holds a certificate of authority from this State or another state at any other time the Commissioner deems necessary. For those organizations transacting business in this State which are not organized in this State, the Commissioner may accept a full report of the last examination of the organization certified by the state officer who supervises those organizations in the other state, if that examination is equivalent to an examination conducted by the Commissioner.

3. The Commissioner shall, in like manner, examine all organizations applying for a certificate of authority.

(Added to NRS by 1983, 2027; A 2007, 3330)

NRS 695D.280 Rehabilitation, liquidation or conservation: Conduct. Any rehabilitation, liquidation or conservation of an organization for dental care shall be deemed to be the rehabilitation, liquidation or conservation of an insurer and must be conducted pursuant to chapter 696B of NRS.

(Added to NRS by 1983, 2027)

NRS 695D.290 Trade practices and frauds: Applicability of provisions to organizations for dental care. The provisions of NRS 686A.010 to 686A.310, inclusive, relating to trade practices and frauds apply to organizations for dental care.

(Added to NRS by 1983, 2027; A 2023, 22)

NRS 695D.300 Disciplinary action: Grounds; penalties.

1. The Commissioner may suspend or revoke any certificate of authority issued to an organization for dental care or impose a fine of not more than $500 for each violation if the Commissioner finds that:

(a) The organization is operating contrary to the information it submitted to the Commissioner for its certificate of authority;

(b) The organization issued a policy to a member which was not approved by the Commissioner;

(d) The organization can no longer meet its obligations to members or prospective members;

(e) The organization or any person on its behalf has advertised its plan in an untrue, misleading, deceptive or unfair manner; or

(f) The organization has failed to comply substantially with this chapter or the regulations of the Commissioner.

2. If the certificate of authority of an organization is suspended, the organization shall not, during the period of the suspension, accept any new members and shall not advertise for or solicit any new members.

3. If the certificate of authority of an organization is revoked, the organization shall proceed, immediately following the order, to terminate its affairs and shall conduct no other business. The Commissioner, by written order, may approve the continued operation of the organization for a specified time if the Commissioner finds that the members need that time to obtain coverage for dental care from another organization or insurer.

(Added to NRS by 1983, 2027)

NRS 695D.310 Disciplinary or other action: Notice; hearing; order.

1. If the Commissioner believes that grounds for denying a certificate of authority or for suspending or revoking a certificate exist, the Commissioner shall notify the organization for dental care in writing, specifying the grounds for the denial, suspension or revocation and fix a time for a hearing on the matter within 30 days after the notice.

2. After the hearing or upon the failure of the organization to appear at the hearing, the Commissioner shall enter a written order of the decision of the Commissioner which must be mailed by certified mail to the organization.

(Added to NRS by 1983, 2028)