Referred to Committee on Health and Human Services
SUMMARY--Makes various changes concerning certain entities that provide health care services through managed care. (BDR 57-393)
FISCAL NOTE: Effect on Local Government: No.
Effect on the State or on Industrial Insurance: Yes.
EXPLANATION - Matter in italics is new; matter in brackets [ ] is material to be omitted.
AN ACT relating to health care; requiring certain entities that provide health care services through managed care to follow certain procedures before denying health care services to an insured; prohibiting such entities from engaging in certain practices that restrict the actions of a provider of health care; requiring such entities to grant or deny a request for emergency medical services within 30 minutes; requiring such entities to file a report containing certain information with the commissioner of insurance; requiring all insurers of health care and managed care organizations to establish a system for resolving complaints of insureds; and providing other matters properly relating thereto.
THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS:
Section 1 Title 57 of NRS is hereby amended by adding thereto a new chapter to consist of the provisions set forth as sections 2 to 23, inclusive, of this act.
Sec. 2 As used in this chapter, unless the context otherwise requires, the words and terms defined in sections 3 to 9, inclusive, of this act have the meanings ascribed to them in those sections.
Sec. 3 "Fee-for-service" means a method of providing or arranging for the provision of health care services wherein an insurer:
1. Reimburses a provider of health care for each service provided to an insured;
2. Allows an insured to choose any provider of health care and does not encourage the use of any specific provider of health care; and
3. Does not require any preauthorization or referral for a specific service to be covered.
Sec. 4 "Insured" means a person covered by a policy of health insurance which provides health care services through managed care, or any other person who is a beneficiary of health care services rendered by a managed care organization or pursuant to a contract with a managed care organization.
Sec. 5 "Managed care" means all methods of providing or arranging for the provision of health care services, other than a method based on fee-for-service. The term includes, without limitation, a health maintenance organization, preferred provider organization, point-of-service plan and exclusive provider organization.
Sec. 6 "Managed care organization" means an organization that provides managed care.
Sec. 7 "Policy of insurance" means any agreement between an insured and an insurer or between an insured and a managed care organization for the provision of health care services.
Sec. 8 "Primary care physician" means a physician whose responsibilities include, without limitation, providing initial and primary health care services to an insured, maintaining the continuity of care for the insured and referring the insured to a specialized provider of health care when necessary.
Sec. 9 "Provider of health care" means any physician, hospital or other person who is licensed or otherwise authorized in this state to furnish any health care service.
Sec. 10 1. The provisions of this chapter apply to each organization and insurer that provides or arranges for the provision of health care services through managed care and each managed care organization that conducts business in this state, including, without limitation, an insurer that issues a policy of health insurance, an insurer that issues a policy of group health insurance, a carrier serving small employers, a fraternal benefit society, a hospital or medical service corporation and a health maintenance organization.
2. In addition to the provisions of this chapter, each managed care organization and each insurer that issues a policy of health insurance which provides health care services through managed care shall comply with any other applicable provision of this Title.
Sec. 11 Each managed care organization and each insurer that issues a policy of health insurance which provides health care services through managed care shall authorize coverage of a health care service that has been recommended for the insured by a provider of health care acting within the scope of his practice if that service is covered by the managed care organization or under the policy, unless:
1. A provider of health care who possesses the relevant education, training and expertise to evaluate the medical condition of the insured denies coverage;
2. The provider of health care has physically examined the insured in a timely manner; and
3. The decision to deny coverage for the health care service and the reason for the decision have been transmitted in writing in a timely manner to the insured and to the provider of health care who recommended the service, the primary care physician of the insured or any other person responsible for providing health care services to the insured, if any.
Sec. 12 1. Each managed care organization and each insurer that issues a policy of health insurance which provides health care services through managed care shall establish written criteria:
(a) Setting forth the manner in which it determines whether to authorize or deny coverage of a health care service; and
(b) Setting forth its method for assuring the quality of health care services provided to an insured.
2. Such written criteria must be:
(a) Established for each health care service covered by the managed care organization or the policy of health insurance;
(b) Established by a provider of health care who provides those services;
(c) Based on generally accepted practices of the medical community at the time the criteria is established;
(d) Updated at least one time each year; and
(e) Made available for public inspection.
Sec. 13 No managed care organization or insurer that issues a policy of health insurance which provides health care services through managed care may restrict or interfere with any communication between a provider of health care and his patient regarding any information that the provider of health care determines is relevant to the health care of the patient.
Sec. 14 1. No managed care organization or insurer that issues a policy of health insurance which provides health care services through managed care may terminate a contract with, demote, refuse to contract with, refuse to compensate or otherwise penalize a provider of health care solely because the provider:
(a) Advocates in private or in public on behalf of a patient;
(b) Assists a patient in seeking reconsideration of a decision by the insurer or managed care organization to deny a health care service; or
(c) Reports a violation of law to an appropriate authority.
2. This section does not prohibit termination of a contract with or disciplinary action against a provider of health care for just cause. For the purposes of this subsection, "just cause" includes, without limitation, taking such action:
(a) Because the provider of health care has committed malpractice;
(b) To prevent the provider of health care from endangering a patient or to discipline the provider of health care for endangering a patient;
(c) When the provider of health care has abused alcohol or a controlled substance in a manner which affected his ability to perform his job;
(d) To prevent the provider of health care from sexually abusing a patient or to discipline the provider of health care for sexually abusing a patient; or
(e) Because of economic necessity.
Sec. 15 No managed care organization or insurer that issues a policy of health insurance which provides health care services through managed care may offer or pay a bonus, provide an incentive or other financial compensation, directly or indirectly, to a provider of health care as an inducement to deny, withhold, limit or delay medically appropriate services to an insured.
Sec. 16 1. If a managed care organization or an insurer that issues a policy of health insurance that provides for health care services through managed care requires preauthorization before it will provide coverage to an insured for an emergency health care service, the managed care organization or insurer shall grant or deny authorization for the service within 30 minutes after receiving a request from or on behalf of the insured.
2. If the authorization for the emergency service is not granted or denied within the time specified in subsection 1, the managed care organization or insurer shall provide coverage for the emergency service requested, whether or not:
(a) The condition actually required immediate medical attention;
(b) The managed care organization or insurer otherwise would have denied coverage; or
(c) The service was provided at a facility or by a provider of health care which is not otherwise covered by the managed care organization or under the policy.
3. A policy of insurance subject to the provisions of this section that is delivered, issued for delivery or renewed on or after October 1, 1997, has the legal effect of including the coverage required by this section, and any provision of the policy or the renewal which is in conflict with this section is void.
Sec. 17 A provider of health care who is responsible for determining the health care services that will be provided to an insured or for establishing a procedure for assuring the quality of care of an insured who:
1. Is employed by a managed care organization or by an insurer that issues a policy of health insurance which provides health care services through managed care; or
2. Has entered into a contract with a managed care organization or with an insurer that issues a policy of health insurance which provides health care services through managed care,
is subject to the same standards and disciplinary procedures as other providers of health care who provide direct care to the insureds of any other policy of health insurance issued in the State of Nevada.
Sec. 18 1. In addition to any other report which is required to be filed with the commissioner, each managed care organization and each insurer that issues a policy of health insurance which provides health care services through managed care shall file with the commissioner, on or before March 1 of each year, a report regarding its methods for assuring the quality of health care services provided to its insureds.
2. Each managed care organization and insurer shall include in its report the criteria, data or studies used to:
(a) Assess the nature, scope, quality and staffing of health care services provided by the managed care organization or insurer; or
(b) Determine any reduction or modification of the provision of health care services.
3. If the managed care organization or insurer is not owned and operated by a public entity and it covers or benefits more than 100 insureds, the report filed pursuant to subsection 1 must include:
(a) A copy of all of its financial reports and income tax returns required to be filed by federal and state tax and security laws;
(b) A statement of any financial interest it has in any other business which is related to health care that is greater than 5 percent of that business or $5,000, whichever is less; and
(c) A description of each complaint filed with or against it that resulted in arbitration, a lawsuit or other legal proceeding, unless disclosure is prohibited by law or a court order.
4. A report filed pursuant to this section must be made available for public inspection within a reasonable time after it is received by the commissioner.
Sec. 19 Any person who:
1. Makes any decision regarding the health care of an insured; and
2. Receives, collects, disburses or invests funds for a managed care organization or for an insurer that issues a policy of health insurance which provides health care services through managed care,
shall act in a fiduciary relationship to the insureds for whom he makes such decisions with respect to such funds.
Sec. 20 1. Each managed care organization and each insurer that issues a policy of health insurance which provides health care services through managed care shall establish a system for resolving any complaints of an insured concerning health care services covered by the managed care organization or under the policy. The system must be approved by the commissioner in consultation with the state board of health.
2. A system for resolving complaints pursuant to subsection 1 must include an initial investigation and review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members on a review board must be insureds who receive health care services from the managed care organization or pursuant to a policy of health insurance issued by the insurer.
3. Except as otherwise provided in this subsection, a determination must be made regarding the complaint or appeal and the insured must be notified by the review board of its determination not later than 30 days after the complaint or appeal is filed. If the complaint involves an imminent and serious threat to the health of the insured, the managed care organization or insurer shall inform the insured immediately of his right to an expedited review of his complaint and the review board shall notify the insured in writing of its determination within 72 hours after the complaint is filed.
4. The commissioner or the state board of health may examine the system for resolving complaints established pursuant to this section at such times as it deems necessary or appropriate.
5. The medical records of a natural person and the records of a physician are not subject to an examination pursuant to subsection 4, but are subject to a properly issued subpoena upon a showing of good cause.
Sec. 21 1. Each managed care organization and each insurer that issues a policy of health insurance which provides health care services through managed care shall submit to the commissioner and the state board of health an annual report regarding its system for resolving complaints established pursuant to section 20 of this act on a form prescribed by the commissioner in consultation with the state board of health which includes, without limitation:
(a) A description of the procedures used for resolving any complaints of an insured;
(b) The total number of complaints and appeals handled through the system for resolving complaints since the last report and a compilation of the causes underlying the complaints filed;
(c) The current status of each complaint and appeal filed; and
(d) The average amount of time that was needed to resolve a complaint and an appeal, if any.
2. Each managed care organization and each insurer shall maintain records of complaints filed with it which concern something other than health care services and shall submit to the commissioner a report summarizing such complaints at such times and in such format as the commissioner may require.
Sec. 22 1. Each managed care organization and each insurer that issues a policy of health insurance which provides health care services through managed care shall provide written notice to an insured, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the insured to file a complaint and to obtain an expedited review pursuant to section 20 of this act. Such notice must be provided to an insured:
(a) Before he pays for any coverage to be provided by the managed care organization or insurer;
(b) Any time that the managed care organization or insurer denies coverage of a health care service or limits coverage of a health care service to an insured; and
(c) Any other time deemed necessary by the commissioner.
2. Any time that a managed care organization or insurer denies coverage of a health care service to an insured it shall notify the insured in writing of:
(a) The reason for denying coverage of the service;
(b) The name of the person responsible for the decision to deny the service;
(c) The criteria by which the managed care organization or insurer determines whether to authorize or deny coverage of a health care service; and
(d) His right to file a complaint.
Sec. 23 Any document required to be filed with the commissioner pursuant to this chapter must be treated as a public record.
Sec. 24 Chapter 689A of NRS is hereby amended by adding thereto the provisions set forth as sections 25, 26 and 27 of this act.
Sec. 25 1. Each insurer that issues a policy of health insurance in this state shall establish a system for resolving any complaints of an insured concerning health care services covered under the policy. The system must be approved by the commissioner in consultation with the state board of health.
2. A system for resolving complaints pursuant to subsection 1 must include an initial investigation and review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members on a review board must be insureds who receive health care services pursuant to a policy of health insurance issued by the insurer.
3. The commissioner or the state board of health may examine the system for resolving complaints established pursuant to this section at such times as it deems necessary or appropriate.
4. The medical records of a natural person and the records of a physician are not subject to an examination pursuant to subsection 3, but are subject to a properly issued subpoena upon a showing of good cause.
Sec. 26 1. Each insurer that issues a policy of health insurance in this state shall submit to the commissioner and the state board of health an annual report regarding its system for resolving complaints established pursuant to section 25 of this act on a form prescribed by the commissioner in consultation with the state board of health which includes, without limitation:
(a) A description of the procedures used for resolving any complaints of an insured;
(b) The total number of complaints and appeals handled through the system for resolving complaints since the last report and a compilation of the causes underlying the complaints filed;
(c) The current status of each complaint and appeal filed; and
(d) The average amount of time that was needed to resolve a complaint and an appeal, if any.
2. Each insurer shall maintain records of complaints filed with it which concern something other than health care services and shall submit to the commissioner a report summarizing such complaints at such times and in such format as the commissioner may require.
Sec. 27 1. Each insurer that issues a policy of health insurance in this state shall provide written notice to an insured, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the insured to file a complaint. Such notice must be provided to an insured:
(a) Before he pays for any coverage to be provided by the insurer;
(b) Any time that the insurer denies coverage of a health care service or limits coverage of a health care service to an insured; and
(c) Any other time deemed necessary by the commissioner.
2. Any time that an insurer denies coverage of a health care service to an insured it shall notify the insured in writing of:
(a) The reason for denying coverage of the service;
(b) The criteria by which the insurer determines whether to authorize or deny coverage of a health care service; and
(c) His right to file a complaint.
Sec. 28 Chapter 689B of NRS is hereby amended by adding thereto the provisions set forth as sections 29, 30 and 31 of this act.
Sec. 29 1. Each insurer that issues a policy of group health insurance in this state shall establish a system for resolving any complaints of an insured concerning health care services covered under the policy. The system must be approved by the commissioner in consultation with the state board of health.
2. A system for resolving complaints pursuant to subsection 1 must include an initial investigation and review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members on a review board must be insureds who receive health care services pursuant to a policy of group health insurance issued by the insurer.
3. The commissioner or the state board of health may examine the system for resolving complaints established pursuant to this section at such times as it deems necessary or appropriate.
4. The medical records of a natural person and the records of a physician are not subject to an examination pursuant to subsection 3, but are subject to a properly issued subpoena upon a showing of good cause.
Sec. 30 1. Each insurer that issues a policy of group health insurance in this state shall submit to the commissioner and the state board of health an annual report regarding its system for resolving complaints established pursuant to section 29 of this act on a form prescribed by the commissioner in consultation with the state board of health which includes, without limitation:
(a) A description of the procedures used for resolving any complaints of an insured;
(b) The total number of complaints and appeals handled through the system for resolving complaints since the last report and a compilation of the causes underlying the complaints filed;
(c) The current status of each complaint and appeal filed; and
(d) The average amount of time that was needed to resolve a complaint and an appeal, if any.
2. Each insurer shall maintain records of complaints filed with it which concern something other than health care services and shall submit to the commissioner a report summarizing such complaints at such times and in such format as the commissioner may require.
Sec. 31 1. Each insurer that issues a policy of group health insurance in this state shall provide written notice to an insured, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the insured to file a complaint. Such notice must be provided to an insured:
(a) Before he pays for any coverage to be provided by the insurer;
(b) Any time that the insurer denies coverage of a health care service or limits coverage of a health care service to an insured; and
(c) Any other time deemed necessary by the commissioner.
2. Any time that an insurer denies coverage of a health care service to an insured it shall notify the insured in writing of:
(a) The reason for denying coverage of the service;
(b) The criteria by which the insurer determines whether to authorize or deny coverage of a health care service; and
(c) His right to file a complaint.
Sec. 32 Chapter 695B of NRS is hereby amended by adding thereto the provisions set forth as sections 33, 34 and 35 of this act.
Sec. 33 1. Each insurer that issues a contract for hospital or medical services in this state shall establish a system for resolving any complaints of an insured concerning health care services covered under the policy. The system must be approved by the commissioner in consultation with the state board of health.
2. A system for resolving complaints pursuant to subsection 1 must include an initial investigation and review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members on a review board must be insureds who receive health care services pursuant to a contract for hospital or medical services issued by the insurer.
3. The commissioner or the state board of health may examine the system for resolving complaints established pursuant to this section at such times as it deems necessary or appropriate.
4. The medical records of a natural person and the records of a physician are not subject to an examination pursuant to subsection 3, but are subject to a properly issued subpoena upon a showing of good cause.
Sec. 34 1. Each insurer that issues a contract for hospital or medical services in this state shall submit to the commissioner and the state board of health an annual report regarding its system for resolving complaints established pursuant to section 33 of this act on a form prescribed by the commissioner in consultation with the state board of health which includes, without limitation:
(a) A description of the procedures used for resolving any complaints of an insured;
(b) The total number of complaints and appeals handled through the system for resolving complaints since the last report and a compilation of the causes underlying the complaints filed;
(c) The current status of each complaint and appeal filed; and
(d) The average amount of time that was needed to resolve a complaint and an appeal, if any.
2. Each insurer shall maintain records of complaints filed with it which concern something other than health care services and shall submit to the commissioner a report summarizing such complaints at such times and in such format as the commissioner may require.
Sec. 35 1. Each insurer that issues a contract for hospital or medical services in this state shall provide written notice to an insured, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the insured to file a complaint. Such notice must be provided to an insured:
(a) Before he pays for any coverage to be provided by the insurer;
(b) Any time that the insurer denies coverage of a health care service or limits coverage of a health care service to an insured; and
(c) Any other time deemed necessary by the commissioner.
2. Any time that an insured denies coverage of a health care service to a beneficiary or subscriber it shall notify the beneficiary or subscriber in writing of:
(a) The reason for denying coverage of the service;
(b) The criteria by which the insurer determines whether to authorize or deny coverage of a health care service; and
(c) His right to file a complaint.
Sec. 36 NRS 695C.050 is hereby amended to read as follows:
695C.0501. Except as otherwise provided in this chapter or in specific provisions of this Title, the provisions of this Title are not applicable to any health maintenance organization granted a certificate of authority under this chapter. This provision does not apply to an insurer licensed and regulated pursuant to this Title except with respect to its activities as a health maintenance organization authorized and regulated pursuant to this chapter.
2. Solicitation of enrollees by a health maintenance organization granted a certificate of authority, or its representatives, must not be construed to violate any provision of law relating to solicitation or advertising by practitioners of a healing art.
3. Any health maintenance organization authorized [under] pursuant to this chapter shall not be deemed to be practicing medicine and is exempt from the provisions of chapter 630 of NRS.
4. The provisions of NRS 695C.110, 695C.170 to 695C.200, inclusive, 695C.250 [, 695C.260] and 695C.265 and sections 20, 21 and 22 of this act do not apply to a health maintenance organization that provides health care services through managed care to recipients of Medicaid pursuant to a contract with the welfare division of the department of human resources. This subsection does not exempt a health maintenance organization from any provision of this chapter for services provided pursuant to any other contract.
Sec. 37 NRS 695C.055 is hereby amended to read as follows:
695C.0551. The provisions of NRS 449.465, 679B.158 and 680B.025 to 680B.060, inclusive, subsections 2, 4, 18, 19 and 32 of NRS 680B.010 and NRS 689C.015 to 689C.350, inclusive, and sections 2 to 23, inclusive, of this act apply to a health maintenance organization.
2. For the purposes of subsection 1, unless the context requires that a provision apply only to insurers, any reference in those sections to "insurer" must be replaced by "health maintenance organization."
Sec. 38 NRS 695C.070 is hereby amended to read as follows:
695C.070Each application for a certificate of authority shall be verified by an officer or authorized representative of the applicant, shall be in a form prescribed by the commissioner, and shall set forth or be accompanied by the following:
1. A copy of the basic organizational document, if any, of the applicant, and all amendments thereto;
2. A copy of the bylaws, rules or regulations, or similar document, if any, regulating the conduct of the internal affairs of the applicant;
3. A list of the names, addresses, and official positions of the persons who are to be responsible for the conduct of the affairs of the applicant, including , without limitation, all members of the board of directors, board of trustees, executive committee, or other governing board or committee, the officers in the case of a corporation, and the partners or members in the case of a partnership or association;
4. A copy of any contract made or to be made between any providers or persons listed in subsection 3 and the applicant;
5. A statement generally describing the health maintenance organization, its health care plan or plans, location of facilities at which health care services will be regularly available to enrollees, the type of health care personnel who will provide the health care services;
6. A copy of the form of evidence of coverage to be issued to the enrollees;
7. A copy of the form of the group contract, if any, which is to be issued to employers, unions, trustees or other organizations;
8. Certified financial statements showing the applicant's assets, liabilities and sources of financial support;
9. The proposed method of marketing the plan, a financial plan which includes a three-year projection of the initial operating results anticipated and the sources of working capital as well as any other sources of funding;
10. A power of attorney duly executed by the applicant, appointing the commissioner and his duly authorized deputies, as the true and lawful attorney of such applicant in and for this state upon whom all lawful process in any legal action or proceeding against the health maintenance organization on a cause of action arising in this state may be served;
11. A statement reasonably describing the geographic area to be served;
12. A description of the complaint procedures to be [utilized] used as required [under NRS 695C.260;] pursuant to section 20 of this act;
13. A description of the procedures and programs to be implemented to meet the quality of health care requirements in NRS 695C.080;
14. A description of the mechanism by which enrollees will be afforded an opportunity to participate in matters of program content [under] pursuant to subsection 2 of NRS 695C.110; and
15. Such other information as the commissioner may require to make the determinations required in NRS 695C.080.
Sec. 39 NRS 695C.330 is hereby amended to read as follows:
695C.3301. The commissioner may suspend or revoke any certificate of authority issued to a health maintenance organization under this chapter if he finds that any of the following conditions exist:
(a) The health maintenance organization is operating significantly in contravention of its basic organizational document, its health care plan or in a manner contrary to that described in and reasonably inferred from any other information submitted [under] pursuant to NRS 695C.060, 695C.070 and 695C.140, unless amendments to those submissions have been filed with and approved by the commissioner;
(b) The health maintenance organization issues evidence of coverage or uses a schedule of charges for health care services which do not comply with the requirements of NRS 695C.170 to 695C.200, inclusive;
(c) The health care plan does not furnish comprehensive health care services as provided for in subsection 2 of NRS 695C.030;
(d) The state board of health certifies to the commissioner that:
(1) The health maintenance organization does not meet the requirements of subsection 2 of NRS 695C.080; or
(2) The health maintenance organization is unable to fulfill its obligations to furnish health care services as required under its health care plan;
(e) The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;
(f) The health maintenance organization has failed to put into effect a mechanism affording the enrollees an opportunity to participate in matters relating to the content of programs [under] pursuant to NRS 695C.110;
(g) The health maintenance organization has failed to put into effect the system for complaints required [by NRS 695C.260] pursuant to section 20 of this act in a manner reasonably to dispose of valid complaints;
(h) The health maintenance organization or any person on its behalf has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive or unfair manner;
(i) The continued operation of the health maintenance organization would be hazardous to its enrollees; or
(j) The health maintenance organization has otherwise failed to substantially comply with this chapter.
2. A certificate of authority must be suspended or revoked only after compliance with the requirements of NRS 695C.340.
3. When the certificate of authority of a health maintenance organization is suspended, the health maintenance organization shall not, during the period of that suspension, enroll any additional groups or new individual contracts, unless those groups or persons were contracted for before the date of suspension.
4. When the certificate of authority of a health maintenance organization is revoked, the organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the organization. It shall engage in no further advertising or solicitation whatsoever. The commissioner may by written order permit such further operation of the organization as he may find to be in the best interest of enrollees to the end that enrollees will be afforded the greatest practical opportunity to obtain continuing coverage for health care.
Sec. 40 NRS 695C.260 is hereby repealed.
Sec. 41 The provisions of this act apply to all contracts for health insurance, managed care or for the provision of health care services entered into or renewed on or after October 1, 1997.
TEXT OF REPEALED SECTION
695C.260Complaint system.
1. Every health maintenance organization shall establish a complaint system which has been approved by the commissioner after consultation with the state board of health to resolve complaints initiated by enrollees concerning health care services. Such system shall provide reasonable procedures for the resolution of complaints. Each health maintenance organization shall submit to the commissioner and the state board of health an annual report in a form prescribed by the commissioner after consultation with the state board of health which shall include:
(a) A description of the procedures of such complaint system; and
(b) The total number of complaints handled through such complaint system and a compilation of causes underlying the complaints filed.
2. The health maintenance organization shall maintain records of complaints filed with it concerning other than health care services and shall submit to the commissioner a summary report at such times and in such format as the commissioner may require. Such complaints involving other persons shall be referred to such persons with a copy to the commissioner.
3. The commissioner or the state board of health may examine such complaint system, subject to the limitations concerning medical records of individuals set forth in subsection 3 of NRS 695C.310.