NAC: CHAPTER 616A - INDUSTRIAL INSURANCE: ADMINISTRATION

[Rev. 5/25/2022 11:33:47 AM]

[NAC-616A Revised Date: 8-18]

CHAPTER 616A - INDUSTRIAL INSURANCE: ADMINISTRATION

GENERAL PROVISIONS

616A.010 Definitions.

616A.015 “Adjuster” defined.

616A.040 “Appeals officer” defined.

616A.050 “Chief” defined.

616A.060 “Claimant” defined.

616A.085 “Electronic transmission” defined.

616A.120 “Fiscal year” defined.

616A.130 “Hearing officer” defined.

616A.170 “Manual” defined.

616A.181 “Office” defined.

616A.190 “Patient” defined.

616A.200 “Payroll” defined.

616A.270 “Vocational rehabilitation” defined.

616A.275 “Workers’ Compensation Section” defined.

616A.290 Construction.

616A.300 Scope.

616A.310 Computation of time.

DIVISION OF INDUSTRIAL RELATIONS OF THE DEPARTMENT OF BUSINESS AND INDUSTRY

616A.390 Administrator of Division: Performance of duties.

616A.400 Correspondence with Division or any of its sections.

616A.410 Time to respond to request of Administrator for information.

616A.420 Declaratory order or advisory opinion of Division.

616A.440 Petition requesting adoption, amendment or repeal of regulation.

POSTERS AND FORMS

616A.460 Informational poster to be displayed by employers.

616A.470 Poster to be displayed by employers with employees who receive tips.

616A.480 Use, alteration, printing and distribution of certain posters and forms.

ADMINISTRATORS

616A.550 Certificate of registration: Grounds for refusal to recommend for final approval.

EXTERNAL REVIEW ORGANIZATIONS

Certification

616A.600 Application for initial issuance of certificate: Generally.

616A.610 Application for initial issuance of certificate: Organization certified or accredited by accrediting body that is nationally recognized.

616A.620 Issuance of certificate by Commissioner.

616A.630 Expiration and renewal of certificate.

616A.640 Fees of Commissioner.

616A.650 Refusal, suspension or revocation of certification: Grounds; surrender of certificate.

616A.660 Duties of organization upon termination of certification or accreditation by accrediting body that is nationally recognized.

Conduct of Business

616A.670 Fees to conduct external reviews.

GENERAL PROVISIONS

NAC 616A.010 Definitions. (NRS 616A.400) As used in this chapter, unless the context otherwise requires, the words and terms defined in:

1. NRS 616A.030 to 616A.360, inclusive; and

2. NAC 616A.015 to 616A.275, inclusive,

Ê have the meanings ascribed to them in those sections.

(Supplied in codification; A by Industrial Insurance System, 10-26-83; 4-20-84; A by Dep’t of Industrial Relations, 10-26-83; A by Industrial Insurance System, 8-16-94; R165-97, 12-31-97, eff. 1-1-98; A by Div. of Industrial Relations by R093-98, 12-18-98; R007-06, 6-1-2006)

NAC 616A.015 “Adjuster” defined. (NRS 616A.400) “Adjuster” means the unit of an insurer or a third-party administrator that is responsible for the administration of claims for compensation for industrial injury or occupational disease in this State, including, without limitation, making determinations relating to compensability and payment of accident benefits.

(Added to NAC by Div. of Industrial Relations by R093-98, 12-18-98, eff. 7-1-99)

NAC 616A.040 “Appeals officer” defined. (NRS 616A.400) “Appeals officer” means an officer appointed pursuant to NRS 616C.340 to conduct hearings of appeals from decisions of hearing officers in cases concerning compensation under chapters 616A to 617, inclusive, of NRS.

[Hearings Div., Practice Rule II subsec. 1, eff. 2-26-80]—(Substituted in revision for NAC 616.014)

NAC 616A.050 “Chief” defined. (NRS 616A.400) “Chief” means the Chief Administrative Officer of the Workers’ Compensation Section.

(Supplied in codification; A by Div. of Industrial Relations by R108-09, 6-30-2010)—(Substituted in revision for NAC 616.015)

NAC 616A.060 “Claimant” defined. (NRS 616A.400) “Claimant” means a person who applies for or claims any right or benefit from an insurer because of any accident under chapters 616A to 616D, inclusive, of NRS or any occupational disease under chapter 617 of NRS.

[Hearings Div., Practice Rule II subsec. 3, eff. 2-26-80]—(NAC A by Dep’t of Industrial Relations, 10-26-83)—(Substituted in revision for NAC 616.016)

NAC 616A.085 “Electronic transmission” defined. (NRS 616A.400, 616A.417, 616C.040, 616C.045) “Electronic transmission” means the sending of information in a legible manner by electronic means, including, without limitation, by facsimile machine, computer, electronic mail or scanner. As used in NRS 616A.417, 616C.040 and 616C.045, the Division will interpret “electronic transmission” to have the meaning ascribed to it in this section.

(Added to NAC by Div. of Industrial Relations by R093-98, eff. 12-18-98)

NAC 616A.120 “Fiscal year” defined. (NRS 679B.130) “Fiscal year” means a 12-month period as determined by the Commissioner.

[Industrial Comm’n, No. 31.101, eff. 10-13-77]—(NAC A by Comm’r of Insurance by R086-98, 6-26-98)

NAC 616A.130 “Hearing officer” defined. (NRS 616A.400) “Hearing officer” means an officer appointed by the Chief of the Hearings Division to conduct initial administrative hearings for review of final determinations made by the staff of an insurer in contested claims for compensation under chapters 616A to 617, inclusive, of NRS.

[Hearings Div., Practice Rule II subsec. 2, eff. 2-26-80]—(Substituted in revision for NAC 616.032)

NAC 616A.170 “Manual” defined. (NRS 679B.130) “Manual” means the classifications and basic rates filed by the Advisory Organization, as defined in NRS 616A.045, and adopted by the Commissioner.

(Added to NAC by Industrial Insurance System, eff. 10-26-83; A by Comm’r of Insurance by R086-98, 6-26-98)

NAC 616A.181 “Office” defined. (NRS 616A.400) “Office” means a place of business which is located in this State and which is operated and maintained by an insurer or third-party administrator. The term does not include the private residence of a person who works for the insurer or third-party administrator.

(Added to NAC by Div. of Industrial Relations by R007-06, eff. 6-1-2006)

NAC 616A.190 “Patient” defined. (NRS 616A.400) “Patient” means any person who receives treatment by a panel physician or chiropractor or any other provider of medical care operating within the scope of his or her license for an industrial injury or occupational disease accepted by the insurer.

[Industrial Comm’n, No. 23.010 subsec. 2, eff. 7-1-73; renumbered as 13.010 subsec. 2, 6-30-82]—(NAC A by Div. of Industrial Insurance Regulation, 2-22-88)—(Substituted in revision for NAC 616.042)

NAC 616A.200 “Payroll” defined. (NRS 616A.400) “Payroll” means, for the purpose of computing premiums for workers’ compensation to be paid by an employer who is not a self-insured employer or a member of an association of self-insured public or private employers, the first $36,000 paid by each employer to any one employee during a policy year and includes, without limitation:

1. Salary.

2. Commissions.

3. Piecework.

4. Incentive pay.

5. Vacation pay.

6. Sick pay.

7. Holiday pay.

8. Wages.

9. Bonuses.

10. Overtime pay.

11. Termination pay.

12. Travel time pay which is compensation for time spent traveling.

13. Tips collected and disbursed by employers which were not paid at the discretion of the customer.

14. Tips not included in subsection 13 which the employee has reported pursuant to 26 U.S.C. § 6053(a).

15. Tool allowance or rental, including vehicle rental or usage, where no accounting is required of the employee.

16. Reasonable market value of board, rent, housing, lodging or similar advantage received from an employer. The value for board and room must be reported at a minimum of $150 monthly, $5 daily or $1.50 per meal and the value for a room alone at a minimum of $50 per month.

17. Cafeteria plan benefits provided to the employee at the employee’s option, in lieu of salary pursuant to section 125 of the Internal Revenue Code of 1986.

18. All deemed wages defined by provisions of chapters 616A to 617, inclusive, of NRS.

(Added to NAC by Div. of Industrial Relations by R093-98, 12-18-98, eff. 7-1-99)

NAC 616A.270 “Vocational rehabilitation” defined. (NRS 616A.400) “Vocational rehabilitation” means the process of assisting an injured employee, whose education, experience, job skills and aptitude can be modified through education or vocational training, to return to gainful employment.

[Industrial Comm’n, No. 14.004, eff. 3-26-82; renumbered as 6.004, 6-30-82]—(NAC A by Div. of Industrial Relations, 1-20-94)—(Substituted in revision for NAC 616.057)

NAC 616A.275 “Workers’ Compensation Section” defined. (NRS 616A.400) “Workers’ Compensation Section” means the Workers’ Compensation Section of the Division of Industrial Relations of the Department of Business and Industry.

(Added to NAC by Div. of Industrial Insurance Regulation, 10-26-83; A by Div. of Industrial Relations by R108-09, 6-30-2010)—(Substituted in revision for NAC 616A.140)

NAC 616A.290 Construction. (NRS 616A.400) The provisions of chapters 616A to 617, inclusive, of NAC must be construed to secure a just, speedy and economical determination of all matters concerning workers’ compensation.

(Added to NAC by Div. of Industrial Relations by R093-98, 12-18-98, eff. 7-1-99)

NAC 616A.300 Scope. (NRS 616A.400) The provisions of chapters 616A to 616D, inclusive, of NAC concern workers’ compensation and govern the determination and payment of benefits and compensation for injuries, disability, occupational disease and death.

[Industrial Comm’n, No. 1.010, eff. 6-30-82]—(NAC A by Dep’t of Industrial Relations, 10-26-83; A by Div. of Industrial Relations by R093-98, 12-18-98)

NAC 616A.310 Computation of time. (NRS 679B.130) In computing any period of time prescribed in chapters 616A to 616D, inclusive, of NAC, the day of the act from which the designated period begins to run must not be included. The last day of the period so computed must be included unless it is a Saturday, Sunday or legal holiday, and in that case, the period runs until the end of the next day which is not a Saturday, Sunday or legal holiday.

[Industrial Comm’n, No. 2.041, eff. 6-30-82]—(Comm’r of Insurance)

DIVISION OF INDUSTRIAL RELATIONS OF THE DEPARTMENT OF BUSINESS AND INDUSTRY

NAC 616A.390 Administrator of Division: Performance of duties. (NRS 616A.400) The Administrator will perform each duty he or she is required to perform pursuant to chapters 616A to 617, inclusive, of NAC or will designate a person to perform the duty on his or her behalf.

(Added to NAC by Div. of Industrial Relations by R105-00, 1-18-2001, eff. 3-1-2001)

NAC 616A.400 Correspondence with Division or any of its sections. (NRS 616A.400)

1. All correspondence and other documents being submitted to the Division or any of its sections must be addressed to the Division, or one of its suboffices, and not to an individual member of its staff. Correspondence and documents shall be deemed to be officially received only if they have been so addressed.

2. Informal communications may be made with individual members of the staff of the Division or any of its sections.

[Industrial Comm’n, No. 2.030, eff. 6-30-82]—(NAC A by Dep’t of Industrial Relations, 10-26-83)—(Substituted in revision for NAC 616.070)

NAC 616A.410 Time to respond to request of Administrator for information. (NRS 616A.400) If the Administrator or the Administrator’s designated agent requests information in writing from an employer, an insurer, a third-party administrator, an organization for managed care or a provider of health care, the person from whom the information is requested shall, except as otherwise provided in NRS 616A.480 or specified in the request, ensure that the response to the request is received by the Administrator or the designated agent within 30 days after receipt of the request.

(Added to NAC by Div. of Industrial Insurance Regulation, eff. 2-22-88; A by Div. of Industrial Relations by R006-97, 12-9-97)

NAC 616A.420 Declaratory order or advisory opinion of Division. (NRS 616A.400) Any interested person may petition the Division for a declaratory order or advisory opinion as to the applicability of any statutory provision, regulation or decision of the Division, or any of its sections, as follows:

1. A petition for a declaratory order or advisory opinion must set forth the name and address of the petitioner and contain a clear and concise statement of the issues to be decided by the Division in its declaratory order or advisory opinion.

2. A petition filed pursuant to this section is submitted for consideration by the Division when an original and three copies of the petition, and any supporting documentation, are filed with the Administrator.

3. The Division will respond to any such petition within 60 days of receipt.

(Added to NAC by Dep’t of Industrial Relations, eff. 6-29-84)—(Substituted in revision for NAC 616.0703)

NAC 616A.440 Petition requesting adoption, amendment or repeal of regulation. (NRS 616A.400)

1. A petition requesting that the Division adopt, amend or repeal a regulation must include:

(a) The name and address of the petitioner;

(b) A clear and concise statement of the regulation to be adopted, amended or repealed; and

2. A person filing a petition shall file an original and three copies of the petition and any supporting documentation with the Administrator of the Division. A petition filed without the required statements or number of copies will be returned to the petitioner and no action will be taken by the Division.

3. The Division will notify the petitioner in writing of its decision concerning the petition within 30 days after it receives the petition.

(Added to NAC by Dep’t of Industrial Relations, eff. 1-8-86)—(Substituted in revision for NAC 616.0735)

POSTERS AND FORMS

NAC 616A.460 Informational poster to be displayed by employers. (NRS 616A.400, 616A.490)

1. Each employer governed by the provisions of chapters 616A to 617, inclusive, of NRS shall prominently display at his or her place of business a poster with the language and in the format specified in Form D-1.

2. The title of the poster must be printed in not less than 20-point bold type. The required statement concerning questions and problems relating to claims must be printed in not less than 12-point bold type. The text appearing on the remainder of the poster must be printed in not less than 10-point type. The poster must be at least 11 inches by 17 inches in size.

3. Each employer shall:

(a) Display the poster as required by this section; and

(b) Advise his or her employees of the name, business address and telephone number of his or her insurer’s or third-party administrator’s adjuster in this State that is located nearest to the employer’s place of business for their claims for workers’ compensation.

4. The poster must be displayed in such a manner as to be readily visible by all employees. A poster must not be displayed unless it has been issued or approved by the Workers’ Compensation Section.

(Added to NAC by Div. of Industrial Insurance Regulation, eff. 2-22-88; A 8-30-91; A by Div. of Industrial Relations, 3-28-94; R093-98, 12-18-98; R093-98, 12-18-98, eff. 7-1-99; R108-09, 6-30-2010)

NAC 616A.470 Poster to be displayed by employers with employees who receive tips. (NRS 616A.400)

1. Each employer governed by the provisions of chapters 616A to 617, inclusive, of NRS who has employees who receive tips shall prominently display a poster with the language and in the format specified in Form D-22.

2. The poster must be at least 8 1/2 inches by 11 inches in size and posted in such a manner as to be readily visible by all employees.

(Added to NAC by Div. of Industrial Insurance Regulation, eff. 2-22-88; A by Div. of Industrial Relations, 3-28-94)—(Substituted in revision for NAC 616.255)

NAC 616A.480 Use, alteration, printing and distribution of certain posters and forms. (NRS 616A.400, 616A.417)

1. The following posters and forms or data must be used by an insurer, employer, injured employee, provider of health care, organization for managed care or third-party administrator in the administration of claims for workers’ compensation:

(a) D-1, Informational Poster - Displayed by Employer. The informational poster must include the language contained in Form D-2, and the name, business address, telephone number and contact person of:

(1) The insurer;

(2) The third-party administrator, if applicable;

(3) The organization for managed care or providers of health care with whom the insurer has contracted to provide medical and health care services, if applicable; and

(4) The name, business address and telephone number of the insurer’s or third-party administrator’s adjuster in this State that is located nearest to the employer’s place of business.

(b) D-2, Brief Description of Your Rights and Benefits if You Are Injured on the Job.

(c) C-1, Notice of Injury or Occupational Disease (Incident Report). One copy of the form must be delivered to the injured employee, and one copy of the form must be retained by the employer. The language contained in Form D-2 must be printed on the reverse side of the employee’s copy of the form, or provided to the employee as a separate document with an affirmative statement acknowledging receipt.

(d) C-3, Employer’s Report of Industrial Injury or Occupational Disease. A copy of the form must be delivered to or the form must be filed by electronic transmission with the insurer or third-party administrator. The form signed by the employer must be retained by the employer. A copy of the form must be delivered to the injured employee. If the employer files the form by electronic transmission, the employer must:

(1) Transmit all fields of the form that are required to be completed, as prescribed by the Administrator.

(2) Sign the form with an electronic symbol representing the signature of the employer that is:

(I) Unique to the employer;

(II) Capable of verification; and

(III) Linked to data in such a manner that the signature is invalidated if the data is altered.

(3) Acknowledge on the form that he or she will maintain the original report of industrial injury or occupational disease for 3 years.

Ê If the employer moves from or ceases operation in this State, the employer shall deliver the original form to the insurer for inclusion in the insurer’s file on the injured employee within 30 days after the move or cessation of operation.

(e) C-4, Employee’s Claim for Compensation/Report of Initial Treatment. A copy of the form must be delivered to the insurer or third-party administrator. A copy of the form must be delivered to or the form must be filed by electronic transmission with the employer. A copy of the form must be delivered to the injured employee. The language contained in Form D-2 must be printed on the reverse side of the injured employee’s copy of the form or provided to the injured employee as a separate document with an affirmative statement acknowledging receipt. The original form signed by the injured employee and the physician or chiropractor who conducted the initial examination of the injured employee must be retained by that physician or chiropractor. If the physician or chiropractor who conducted the initial examination files the form by electronic transmission, the physician or chiropractor must:

(1) Transmit all fields of the form that are required to be completed, as prescribed by the Administrator.

(2) Sign the form with an electronic symbol representing the signature of the physician or chiropractor that is:

(I) Unique to the physician or chiropractor;

(II) Capable of verification; and

(III) Linked to data in such a manner that the signature is invalidated if the data is altered.

(3) Acknowledge on the form that he or she will maintain the original form for the claim for compensation for 3 years.

Ê If the physician or chiropractor who conducted the initial examination moves from or ceases treating patients in this State, the physician or chiropractor shall deliver the original form to the insurer for inclusion in the insurer’s file on the injured employee within 30 days after the move or cessation of treatment of patients.

(f) D-5, Wage Calculation Form for Claims Agent’s Use.

(g) D-6, Injured Employee’s Request for Compensation.

(h) D-7, Explanation of Wage Calculation.

(i) D-8, Employer’s Wage Verification Form.

(j) D-9(a), Permanent Partial Disability Award Calculation Worksheet.

(k) D-9(b), Permanent Partial Disability Award Calculation Worksheet for Disability Over 25 Percent Body Basis.

(l) D-9(c), Permanent Partial Disability Worksheet for Stress Claims Pursuant to NRS 616C.180.

(m) D-10(a), Election of Method of Payment of Compensation.

(n) D-10(b), Election of Method of Payment of Compensation for Disability Greater than 25 Percent.

(o) D-11, Reaffirmation/Retraction of Lump Sum Request.

(p) D-12(a), Request for Hearing - Contested Claim.

(q) D-12(b), Request for Hearing - Uninsured Employer.

(r) D-13, Injured Employee’s Right to Reopen a Claim Which Has Been Closed.

(s) D-14, Permanent Total Disability Report of Employment.

(t) D-15, Election for Nevada Workers’ Compensation Coverage for Out-of-State Injury.

(u) D-16, Notice of Election for Compensation Benefits Under the Uninsured Employer Statutes.

(v) D-17, Employee’s Claim for Compensation - Uninsured Employer.

(w) D-18, Assignment of Claim for Workers’ Compensation - Uninsured Employer.

(x) D-21, Fatality Report.

(y) D-22, Notice to Employees - Tip Information.

(z) D-23, Employee’s Declaration of Election to Report Tips.

(aa) D-24, Request for Reimbursement of Expenses for Travel and Lost Wages.

(bb) D-25, Affirmation of Compliance with Mandatory Industrial Insurance Requirements.

(cc) D-26, Application for Reimbursement of Claim-Related Travel Expenses.

(dd) D-27, Interest Calculation for Compensation Due.

(ee) D-28, Rehabilitation Lump Sum Request.

(ff) D-29, Lump Sum Rehabilitation Agreement.

(gg) D-30, Notice of Claim Acceptance.

(hh) D-31, Notice of Intention to Close Claim.

(ii) D-32, Authorization Request for Additional Chiropractic Treatment.

(jj) D-33, Authorization Request for Additional Physical Therapy Treatment.

(kk) D-34, CMS 1500 Billing Form.

(ll) D-35, Request for a Rotating Rating Physician or Chiropractor.

(mm) D-36, Request for Additional Medical Information and Medical Release.

(nn) D-37, Insurer’s Subsequent Injury Checklist.

(oo) D-38, Injured Worker Index System Claims Registration Document.

(pp) D-39, Physician’s Progress Report - Certification of Disability.

(qq) D-41, International Association of Industrial Accident Boards and Commissions POC 1.

(rr) D-43, Employee’s Election to Reject Coverage and Election to Waive the Rejection of Coverage for Excluded Persons.

(ss) D-44, Election of Coverage by Employer; Employer Withdrawal of Election of Coverage.

(tt) D-45, Sole Proprietor Coverage.

(uu) D-46, Temporary Partial Disability Calculation Worksheet.

(vv) D-48, Proof of Coverage Notice.

(ww) D-49, Information Page.

(xx) D-50, Policy Termination, Cancellation and Reinstatement Notice.

(yy) D-52, CMS (UB-92).

(zz) D-53, Alternative Choice of Physician or Chiropractor and Referral to a Specialist.

2. In addition to the forms specified in subsection 1, the following forms must be used by each insurer in the administration of a claim for an occupational disease:

(a) OD-1, Firemen and Police Officers’ Medical History Form.

(b) OD-2, Firemen and Police Officers’ Lung Examination Form.

(d) OD-4, Firemen and Police Officers’ Limited Heart Examination Form.

(e) OD-5, Firemen and Police Officers’ Hearing Examination Form.

(f) OD-6, Firemen and Police Officers’ Sample Letter.

(g) OD-7, Firemen and Police Officers’ Physical Examination Information.

(h) OD-8, Occupational Disease Claim Reporting.

3. The forms listed in this section must be accurately completed, including, without limitation, a signature and a date if required by the form. An insurer or employer may designate a third-party administrator as an agent to sign any form listed in this section.

4. An insurer, employer, injured employee, provider of health care, organization for managed care or third-party administrator may not use a different form or change a form without the prior written approval of the Administrator.

5. The Workers’ Compensation Section will be responsible for printing and distributing the following forms:

(a) C-4, Employee’s Claim for Compensation/Report of Initial Treatment;

(b) D-12(b), Request for Hearing - Uninsured Employer;

(d) D-17, Employee’s Claim for Compensation - Uninsured Employer; and

(e) D-18, Assignment of Claim for Workers’ Compensation - Uninsured Employer.

6. Each insurer or third-party administrator is responsible for printing and distributing all other forms listed in this section. The provisions of this subsection do not prohibit an insurer, employer, provider of health care, organization for managed care or third-party administrator from providing any form listed in this section.

7. Upon the request of the Administrator, an insurer, employer, provider of health care, organization for managed care or third-party administrator shall submit to the Administrator a copy of any form used in this State by the insurer, employer, provider of health care, organization for managed care or third-party administrator in the administration of claims for workers’ compensation.

(Added to NAC by Div. of Industrial Insurance Regulation, eff. 2-22-88; A by Div. of Industrial Relations, 3-28-94; R104-97, 3-6-98; R098-98, 12-18-98; R093-98, 12-18-98; R093-98, 12-18-98, eff. 7-1-99; R071-99, 10-29-99; R105-00, 1-18-2001, eff. 3-1-2001; R118-02, 9-7-2005; R108-09, 6-30-2010)

ADMINISTRATORS

NAC 616A.550 Certificate of registration: Grounds for refusal to recommend for final approval. (NRS 616A.400)

1. The Division may refuse to recommend for final approval an application for a certificate of registration as an administrator pursuant to subsection 3 of NRS 683A.08524 because:

(a) A principal of the applicant was formerly a principal of a third-party administrator or insurer which has an outstanding debt owing to the Division or an injured employee;

(b) The information in the application reveals that the applicant does not maintain, based on the experience, caseload and number of clients of its adjuster, a sufficient number of experienced and qualified persons to properly administer claims; or

(c) Any other reason the Division determines may hinder the prompt and efficient payment of compensation to injured employees.

2. As used in this section:

(a) “Debt” includes, without limitation, an administrative fine, a benefit penalty or a penalty imposed pursuant to subsection 4 of NRS 616C.065.

(b) “Principal” means an owner, manager, officer, proprietor or any other person having a significant degree of control over the administration of claims.

(Added to NAC by Div. of Industrial Relations by R149-09, eff. 10-23-2013)

EXTERNAL REVIEW ORGANIZATIONS

Certification

NAC 616A.600 Application for initial issuance of certificate: Generally. (NRS 616A.469, 679B.130) Except as otherwise provided in NAC 616A.610, an external review organization applying for the initial issuance of a certificate to conduct external reviews must submit to the Commissioner, on a form prescribed by the Commissioner, an application in writing and must provide to the Commissioner at the time of application:

1. A written statement that identifies:

(a) The number of external reviewers that the external review organization employs, contracts with or otherwise retains to conduct external reviews;

(b) The specialty of each external reviewer;

(d) The schedule of fees that the external review organization will charge to conduct an external review.

2. A written summary of the procedures that the external review organization will use to:

(a) Ensure that an external reviewer employed, contracted with or otherwise retained by the external review organization is qualified to conduct a specific external review;

(b) Ensure that the external review organization and any employee, agent or contractor of the external review organization does not have a conflict of interest as set forth in NRS 616A.469; and

3. A written affidavit that:

(a) The information contained in the application and any accompanying materials are complete and correct;

(b) The external review organization will conduct external reviews in accordance with NRS 616A.469 and 616C.363;

(c) The external review organization and any employee, agent or contractor of the external review organization will avoid a conflict of interest as set forth in NRS 616A.469; and

(d) The external review organization is not affiliated with:

(1) An organization for managed care which provides comprehensive medical and health care services to employees for injuries or diseases pursuant to chapters 616A to 617, inclusive, of NRS;

(2) An insurer;

(3) A third-party administrator; or

(4) A national, state or local trade association.

4. All applicable fees required, including, without limitation, all applicable fees required pursuant to NAC 616A.640, for the initial issuance of a certificate to conduct external reviews.

(Added to NAC by Comm’r of Insurance by R127-03, eff. 12-16-2003; A by R103-09, 1-28-2010)

NAC 616A.610 Application for initial issuance of certificate: Organization certified or accredited by accrediting body that is nationally recognized. (NRS 616A.469, 679B.130) If an external review organization has been certified or accredited as an external review organization by an accrediting body that is nationally recognized, an external review organization applying for the initial issuance of a certificate to conduct external reviews must submit to the Commissioner, on a form prescribed by the Commissioner, an application in writing and must provide to the Commissioner at the time of application:

1. Proof that the external review organization has been certified or accredited as an external review organization by an accrediting body that is nationally recognized;

2. A copy of the certification or accreditation standards of the accrediting body;

3. A copy of the most recent review of the external review organization conducted by the accrediting body;

4. A copy of the schedule of fees that the external review organization will charge to conduct an external review; and

5. All applicable fees required, including, without limitation, all applicable fees required pursuant to NAC 616A.640, for the initial issuance of a certificate to conduct external reviews.

(Added to NAC by Comm’r of Insurance by R127-03, eff. 12-16-2003; A by R103-09, 1-28-2010)

NAC 616A.620 Issuance of certificate by Commissioner. (NRS 616A.469, 679B.130) Except as otherwise provided in NAC 616A.650, if an external review organization applying for the initial issuance of a certificate to conduct external reviews submits the application and accompanying materials required pursuant to NAC 616A.600 or 616A.610, the Commissioner will issue to the applicant a certificate to conduct external reviews.

(Added to NAC by Comm’r of Insurance by R127-03, eff. 12-16-2003)

NAC 616A.630 Expiration and renewal of certificate. (NRS 616A.469, 679B.130)

1. In accordance with NRS 616A.469, a certificate to conduct external reviews expires 1 year after the date the certificate is issued by the Commissioner.

2. Except as otherwise provided in NAC 616A.650, the Commissioner will issue a renewal of a certificate to conduct external reviews if the external review organization submits to the Commissioner:

(a) On a form prescribed by the Commissioner, an application in writing for the renewal of the certificate to conduct external reviews;

(b) A copy of the schedule of fees that the external review organization will charge to conduct an external review; and

(c) All applicable fees required, including, without limitation, all applicable fees required pursuant to NAC 616A.640, for the renewal of a certificate to conduct external reviews.

(Added to NAC by Comm’r of Insurance by R127-03, eff. 12-16-2003; A by R103-09, 1-28-2010)

NAC 616A.640 Fees of Commissioner. (NRS 616A.469, 679B.130) The Commissioner will charge and collect:

1. Except as otherwise provided in subsection 2, from an external review organization submitting an application for the initial issuance of a certificate to conduct external reviews pursuant to NAC 616A.600 or 616A.610, a fee of $400.

2. From an external review organization submitting an application for:

(a) The initial issuance of a certificate to conduct external reviews pursuant to NAC 616A.600 or 616A.610; and

(b) The initial issuance of a certificate to conduct external reviews pursuant to NRS 683A.371, and the regulations adopted pursuant thereto,

Ê a fee of $600.

3. From an external review organization submitting an application for the renewal of a certificate to conduct external reviews pursuant to NAC 616A.630, a fee of $100.

4. From an external review organization, all applicable fees required pursuant to NRS 680C.110.

(Added to NAC by Comm’r of Insurance by R127-03, eff. 12-16-2003; A by R103-09, 1-28-2010)

NAC 616A.650 Refusal, suspension or revocation of certification: Grounds; surrender of certificate. (NRS 616A.469, 679B.130)

1. The Commissioner may refuse to issue or renew, or may suspend or revoke, a certificate to conduct external reviews if the Commissioner determines that an external review organization:

(a) Has violated the provisions of NRS 616A.469 or 616C.363, or NAC 616A.600 to 616A.670, inclusive;

(b) Has had a license, certificate or registration to operate as an external review organization denied for cause, suspended or revoked by any other state; or

(c) Has misrepresented facts on an application submitted to the Commissioner for the issuance or renewal of a certificate to conduct external reviews.

2. If the Commissioner refuses to renew, revokes or suspends a certificate to conduct external reviews, the external review organization shall surrender the certificate to the Commissioner.

(Added to NAC by Comm’r of Insurance by R127-03, eff. 12-16-2003)

NAC 616A.660 Duties of organization upon termination of certification or accreditation by accrediting body that is nationally recognized. (NRS 616A.469, 679B.130) An external review organization issued a certificate to conduct external reviews by the Commissioner pursuant to NAC 616A.610 shall:

1. Notify the Commissioner if the accrediting body revokes, suspends or otherwise terminates the certification or accreditation of the external review organization; and

2. Provide to the Commissioner a copy of the findings of any review of the external review organization conducted by the accrediting body.

(Added to NAC by Comm’r of Insurance by R127-03, eff. 12-16-2003)

Conduct of Business

NAC 616A.670 Fees to conduct external reviews. (NRS 616A.469, 616C.363, 679B.130) The fees an external review organization issued a certificate to conduct external reviews may charge to conduct external reviews:

1. Must be reasonable;

2. Must not exceed the fees set forth in the schedule of fees submitted by the external review organization to the Commissioner pursuant to NAC 616A.600, 616A.610 or 616A.630; and

3. Must comply with all applicable statutes and regulations.

(Added to NAC by Comm’r of Insurance by R127-03, eff. 12-16-2003)