[Rev. 11/22/2013 10:32:45 AM--2013]
[NAC-695G Revised Date: 11-04]
GENERAL PROVISIONS
695G.010 Definitions.
695G.020 “Commissioner” defined.
695G.030 “Division” defined.
695G.040 “Managed care organization” defined.
SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS
695G.100 Requirements for approval.
695G.110 Annual report.
GENERAL PROVISIONS
NAC 695G.010 Definitions. (NRS 679B.130) As used in this chapter, unless the context otherwise requires, the words and terms defined in NAC 695G.020, 695G.030 and 695G.040 have the meanings ascribed to them in those sections.
(Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)
NAC 695G.020 “Commissioner” defined. (NRS 679B.130) “Commissioner” means the Commissioner of Insurance.
(Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)
NAC 695G.030 “Division” defined. (NRS 679B.130) “Division” means the Division of Insurance of the Department of Business and Industry.
(Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)
NAC 695G.040 “Managed care organization” defined. (NRS 679B.130) “Managed care organization” has the meaning ascribed to it in NRS 695G.050.
(Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)
SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS
NAC 695G.100 Requirements for approval. (NRS 679B.130, 695G.200) To obtain approval of a system for resolving complaints of insureds from the Commissioner as required pursuant to NRS 695G.200, a managed care organization must:
1. Demonstrate that the system will include the external review of a final adverse determination.
2. Submit to the Division:
(a) The name and title of the employee responsible for the system;
(b) A description of the procedure used to notify an insured of the decision regarding his complaint; and
(c) A copy of the explanation of rights and procedures which is to be provided to insureds pursuant to NRS 695G.230.
(Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99; A by R132-03, 4-16-2004)
NAC 695G.110 Annual report. (NRS 679B.130, 695G.220)
1. A managed care organization shall submit its annual report regarding its system for resolving complaints as required pursuant to NRS 695G.220 on or before June 1 of each year. The managed care organization shall retain a copy of the annual report for at least 3 years or until the next examination conducted by the Division, whichever is longer.
2. The managed care organization is not required to include in the annual report information concerning an oral inquiry by an insured relating to a misunderstanding or miscommunication if the misunderstanding or miscommunication was resolved within 1 working day after the inquiry was made. If the misunderstanding or miscommunication was not resolved within 1 working day, the managed care organization shall report it as a complaint in the annual report.
(Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99; A by R008-02, 5-23-2002)