Assembly Bill No. 79–Assemblymen Buckley, Gibbons, Anderson, Manendo, Giunchigliani, Andonov, Angle, Arberry, Atkinson, Beers, Brown, Carpenter, Chowning, Christensen, Claborn, Collins, Conklin, Geddes, Goicoechea, Goldwater, Grady, Gustavson, Hardy, Hettrick, Horne, Knecht, Koivisto, Leslie, Mabey, Marvel, McClain, McCleary, Mortenson, Oceguera, Ohrenschall, Parks, Perkins, Pierce, Sherer, Weber and Williams
Joint Sponsors: Senators Titus, Neal and O’Connell
CHAPTER..........
AN ACT relating to health care; requiring an external review organization to be certified by the Commissioner of Insurance before conducting an external review of a final adverse determination of a managed care organization, health maintenance organization or certain insurers; authorizing an insured under certain health care plans to submit to a managed care organization, health maintenance organization or certain insurers a request for such a review under certain circumstances; requiring an external review organization to approve, modify or reverse a final adverse determination within a certain period; providing that an external review organization is not liable in a civil action for damages relating to a determination issued by the external review organization under certain circumstances; and providing other matters properly relating thereto.
THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN
SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS:
1-1 Section 1. Chapter 683A of NRS is hereby amended by
1-2 adding thereto the provisions set forth as sections 2 and 3 of this act.
1-3 Sec. 2. 1. An external review organization shall not
1-4 conduct an external review of a final adverse determination
1-5 pursuant to sections 16 to 28, inclusive, of this act unless the
1-6 external review organization is certified in accordance with
1-7 regulations adopted by the Commissioner. The regulations must
1-8 include, without limitation, provisions setting forth:
1-9 (a) The manner in which an external review organization may
1-10 apply for a certificate and the requirements for the issuance and
1-11 renewal of the certificate pursuant to this section;
1-12 (b) The grounds for which the Commissioner may refuse to
1-13 issue, suspend, revoke or refuse to renew a certificate issued
1-14 pursuant to this section; and
1-15 (c) The manner and circumstances under which an external
1-16 review organization is required to conduct its business.
2-1 2. A certificate issued pursuant to this section expires 1 year
2-2 after it is issued and may be renewed in accordance with
2-3 regulations adopted by the Commissioner.
2-4 3. Except as otherwise provided in subsection 6, before the
2-5 Commissioner may certify an external review organization, the
2-6 external review organization must:
2-7 (a) Demonstrate to the satisfaction of the Commissioner that it
2-8 is able to carry out, in a timely manner, the duties of an external
2-9 review organization set forth in this section and sections 16 to 28,
2-10 inclusive, of this act. The demonstration must include, without
2-11 limitation, proof that the external review organization employs,
2-12 contracts with or otherwise retains only persons who are qualified
2-13 because of their education, training, professional licensing and
2-14 experience to perform the duties assigned to those persons; and
2-15 (b) Provide assurances satisfactory to the Commissioner that
2-16 the external review organization will:
2-17 (1) Conduct its external review activities in accordance with
2-18 the provisions of this section and sections 16 to 28, inclusive, of
2-19 this act;
2-20 (2) Provide its determinations in a clear, consistent,
2-21 thorough and timely manner; and
2-22 (3) Avoid conflicts of interest.
2-23 4. For the purposes of this section, an external review
2-24 organization has a conflict of interest if the external review
2-25 organization or any employee, agent or contractor of the external
2-26 review organization who conducts an external review has a
2-27 material professional, familial or financial interest in any person
2-28 who has a substantial interest in the outcome of the external
2-29 review, including, without limitation:
2-30 (a) The insured;
2-31 (b) The insurer or any officer, director or management
2-32 employee of the insurer;
2-33 (c) The provider of health care services that are provided or
2-34 proposed to be provided, his partner or any other member of his
2-35 medical group or practice;
2-36 (d) The hospital or other licensed health care facility where the
2-37 health care service or treatment that is subject to external review
2-38 has been or will be provided; or
2-39 (e) A developer, manufacturer or other person who has a
2-40 substantial interest in the principal procedure, equipment, drug,
2-41 device or other instrumentality that is the subject of the external
2-42 review.
2-43 5. The Commissioner shall not certify an external review
2-44 organization that is affiliated with:
2-45 (a) A health care plan; or
2-46 (b) A national, state or local trade association.
3-1 6. An external review organization that is certified or
3-2 accredited by an accrediting body that is nationally recognized
3-3 shall be deemed to have satisfied all the conditions and
3-4 qualifications required for certification pursuant to this section.
3-5 7. The Commissioner may charge and collect a fee for
3-6 issuing or renewing a certificate of an external review
3-7 organization pursuant to this section. The fee must not exceed the
3-8 cost of issuing or renewing the certificate.
3-9 8. The Commissioner shall annually prepare and make
3-10 available to the general public a list that includes the name of
3-11 each external review organization which is issued a certificate or
3-12 whose certificate is renewed pursuant to this section during the
3-13 year immediately preceding the year in which the Commissioner
3-14 prepares the list.
3-15 9. As used in this section:
3-16 (a) “Adverse determination” has the meaning ascribed to it in
3-17 section 16 of this act.
3-18 (b) “External review organization” has the meaning ascribed
3-19 to it in section 19 of this act.
3-20 (c) “Provider of health care” means any physician or other
3-21 person who is licensed in this state or is licensed, certified or
3-22 otherwise authorized by any other state to provide any health care
3-23 service.
3-24 Sec. 3. As soon as practicable after preparing an annual list
3-25 of external review organizations pursuant to subsection 8 of
3-26 section 2 of this act, the Commissioner shall submit a copy of the
3-27 list to the Office for Consumer Health Assistance. If a change
3-28 occurs in the list, the Commissioner shall notify the Office for
3-29 Consumer Health Assistance of the change.
3-30 Sec. 4. NRS 689A.745 is hereby amended to read as follows:
3-31 689A.745 1. [Each] Except as otherwise provided in
3-32 subsection 4, each insurer that issues a policy of health insurance in
3-33 this state shall establish a system for resolving any complaints of an
3-34 insured concerning health care services covered under the policy.
3-35 The system must be approved by the Commissioner in consultation
3-36 with the State Board of Health.
3-37 2. A system for resolving complaints established pursuant to
3-38 subsection 1 must include an initial investigation, a review of the
3-39 complaint by a review board and a procedure for appealing a
3-40 determination regarding the complaint. The majority of the members
3-41 on a review board must be insureds who receive health care services
3-42 pursuant to a policy of health insurance issued by the insurer.
3-43 3. The Commissioner or the State Board of Health may
3-44 examine the system for resolving complaints established pursuant to
3-45 [this section] subsection 1 at such times as either deems necessary
3-46 or appropriate.
4-1 4. Each insurer that issues a policy of health insurance in
4-2 this state that provides, delivers, arranges for, pays for or
4-3 reimburses any cost of health care services through managed care
4-4 shall provide a system for resolving any complaints of an insured
4-5 concerning those health care services that complies with the
4-6 provisions of sections 16 to 28, inclusive, of this act and NRS
4-7 695G.200 to 695G.230, inclusive.
4-8 Sec. 5. NRS 689A.750 is hereby amended to read as follows:
4-9 689A.750 1. Each insurer that issues a policy of health
4-10 insurance in this state shall submit to the Commissioner and the
4-11 State Board of Health an annual report regarding its system for
4-12 resolving complaints established pursuant to subsection 1 of NRS
4-13 689A.745 on a form prescribed by the Commissioner in consultation
4-14 with the State Board of Health which includes, without limitation:
4-15 (a) A description of the procedures used for resolving any
4-16 complaints of an insured;
4-17 (b) The total number of complaints and appeals handled through
4-18 the system for resolving complaints since the last report and a
4-19 compilation of the causes underlying the complaints filed;
4-20 (c) The current status of each complaint and appeal filed; and
4-21 (d) The average amount of time that was needed to resolve a
4-22 complaint and an appeal, if any.
4-23 2. Each insurer shall maintain records of complaints filed with
4-24 it which concern something other than health care services and shall
4-25 submit to the Commissioner a report summarizing such complaints
4-26 at such times and in such format as the Commissioner may require.
4-27 Sec. 6. NRS 689B.0285 is hereby amended to read as follows:
4-28 689B.0285 1. [Each] Except as otherwise provided in
4-29 subsection 4, each insurer that issues a policy of group health
4-30 insurance in this state shall establish a system for resolving any
4-31 complaints of an insured concerning health care services covered
4-32 under the policy. The system must be approved by the
4-33 Commissioner in consultation with the State Board of Health.
4-34 2. A system for resolving complaints established pursuant to
4-35 subsection 1 must include an initial investigation, a review of the
4-36 complaint by a review board and a procedure for appealing a
4-37 determination regarding the complaint. The majority of the members
4-38 on a review board must be insureds who receive health care services
4-39 pursuant to a policy of group health insurance issued by the insurer.
4-40 3. The Commissioner or the State Board of Health may
4-41 examine the system for resolving complaints established pursuant to
4-42 [this section] subsection 1 at such times as either deems necessary
4-43 or appropriate.
4-44 4. Each insurer that issues a policy of group health insurance
4-45 in this state that provides, delivers, arranges for, pays for or
4-46 reimburses any cost of health care services through managed care
5-1 shall provide a system for resolving any complaints of an insured
5-2 concerning the health care services that complies with the
5-3 provisions of sections 16 to 28, inclusive, of this act and NRS
5-4 695G.200 to 695G.230, inclusive.
5-5 Sec. 7. NRS 689B.029 is hereby amended to read as follows:
5-6 689B.029 1. Each insurer that issues a policy of group health
5-7 insurance in this state shall submit to the Commissioner and the
5-8 State Board of Health an annual report regarding its system for
5-9 resolving complaints established pursuant to subsection 1 of NRS
5-10 689B.0285 on a form prescribed by the Commissioner in
5-11 consultation with the State Board of Health which includes, without
5-12 limitation:
5-13 (a) A description of the procedures used for resolving any
5-14 complaints of an insured;
5-15 (b) The total number of complaints and appeals handled through
5-16 the system for resolving complaints since the last report and a
5-17 compilation of the causes underlying the complaints filed;
5-18 (c) The current status of each complaint and appeal filed; and
5-19 (d) The average amount of time that was needed to resolve a
5-20 complaint and an appeal, if any.
5-21 2. Each insurer shall maintain records of complaints filed with
5-22 it which concern something other than health care services and shall
5-23 submit to the Commissioner a report summarizing such complaints
5-24 at such times and in such format as the Commissioner may require.
5-25 Sec. 8. NRS 689C.156 is hereby amended to read as follows:
5-26 689C.156 1. As a condition of transacting business in this
5-27 state with small employers, a carrier shall actively market to a small
5-28 employer each health benefit plan which is actively marketed in this
5-29 state by the carrier to any small employer in this state. The health
5-30 insurance plans marketed pursuant to this section by the carrier must
5-31 include, without limitation, a basic health benefit plan and a
5-32 standard health benefit plan. A carrier shall be deemed to be actively
5-33 marketing a health benefit plan when it makes available any of its
5-34 plans to a small employer that is not currently receiving coverage
5-35 under a health benefit plan issued by that carrier.
5-36 2. A carrier shall issue to a small employer any health benefit
5-37 plan marketed in accordance with this section if the eligible small
5-38 employer applies for the plan and agrees to make the required
5-39 premium payments and satisfy the other reasonable provisions of the
5-40 health benefit plan that are not inconsistent with NRS 689C.015 to
5-41 689C.355, inclusive, and 689C.610 to 689C.980, inclusive, except
5-42 that a carrier is not required to issue a health benefit plan to a self-
5-43 employed person who is covered by, or is eligible for coverage
5-44 under, a health benefit plan offered by another employer.
5-45 3. If a health benefit plan marketed pursuant to this section
5-46 provides, delivers, arranges for, pays for or reimburses any cost of
6-1 health care services through managed care, the carrier shall
6-2 provide a system for resolving any complaints of an employee
6-3 concerning those health care services that complies with the
6-4 provisions of sections 16 to 28, inclusive, of this act and NRS
6-5 695G.200 to 695G.230, inclusive.
6-6 Sec. 9. NRS 695B.380 is hereby amended to read as follows:
6-7 695B.380 1. [Each] Except as otherwise provided in
6-8 subsection 4, each insurer that issues a contract for hospital or
6-9 medical services in this state shall establish a system for resolving
6-10 any complaints of an insured concerning health care services
6-11 covered under the policy. The system must be approved by the
6-12 Commissioner in consultation with the State Board of Health.
6-13 2. A system for resolving complaints established pursuant to
6-14 subsection 1 must include an initial investigation, a review of the
6-15 complaint by a review board and a procedure for appealing a
6-16 determination regarding the complaint. The majority of the members
6-17 on a review board must be insureds who receive health care services
6-18 pursuant to a contract for hospital or medical services issued by the
6-19 insurer.
6-20 3. The Commissioner or the State Board of Health may
6-21 examine the system for resolving complaints established pursuant to
6-22 [this section] subsection 1 at such times as either deems necessary
6-23 or appropriate.
6-24 4. Each insurer that issues a contract specified in subsection
6-25 1 shall, if the contract provides, delivers, arranges for, pays for or
6-26 reimburses any cost of health care services through managed care,
6-27 provide a system for resolving any complaints of an insured
6-28 concerning those health care services that complies with the
6-29 provisions of sections 16 to 28, inclusive, of this act and NRS
6-30 695G.200 to 695G.230, inclusive.
6-31 Sec. 10. NRS 695B.390 is hereby amended to read as follows:
6-32 695B.390 1. Each insurer that issues a contract for hospital or
6-33 medical services in this state shall submit to the Commissioner and
6-34 the State Board of Health an annual report regarding its system for
6-35 resolving complaints established pursuant to subsection 1 of NRS
6-36 695B.380 on a form prescribed by the Commissioner in consultation
6-37 with the State Board of Health which includes, without limitation:
6-38 (a) A description of the procedures used for resolving any
6-39 complaints of an insured;
6-40 (b) The total number of complaints and appeals handled through
6-41 the system for resolving complaints since the last report and a
6-42 compilation of the causes underlying the complaints filed;
6-43 (c) The current status of each complaint and appeal filed; and
6-44 (d) The average amount of time that was needed to resolve a
6-45 complaint and an appeal, if any.
7-1 2. Each insurer shall maintain records of complaints filed with
7-2 it which concern something other than health care services and shall
7-3 submit to the Commissioner a report summarizing such complaints
7-4 at such times and in such format as the Commissioner may require.
7-5 Sec. 11. NRS 695C.070 is hereby amended to read as follows:
7-6 695C.070 Each application for a certificate of authority [shall]
7-7 must be verified by an officer or authorized representative of
7-8 the applicant, [shall] must be in a form prescribed by the
7-9 Commissioner, and [shall] must set forth or be accompanied by the
7-10 following:
7-11 1. A copy of the basic organizational document, if any, of the
7-12 applicant, and all amendments thereto;
7-13 2. A copy of the bylaws, rules or regulations, or a similar
7-14 document, if any, regulating the conduct of the internal affairs of the
7-15 applicant;
7-16 3. A list of the names, addresses[,] and official positions of the
7-17 persons who [are to] will be responsible for the conduct of the
7-18 affairs of the applicant, including all members of the board of
7-19 directors, board of trustees, executive committee, or other governing
7-20 board or committee, the officers in the case of a corporation, and the
7-21 partners or members in the case of a partnership or association;
7-22 4. A copy of any contract made or to be made between any
7-23 providers or persons listed in subsection 3 and the applicant;
7-24 5. A statement generally describing the health maintenance
7-25 organization, its health care plan or plans, the location of facilities at
7-26 which health care services will be regularly available to enrollees[,]
7-27 and the type of health care personnel who will provide the health
7-28 care services;
7-29 6. A copy of the form of evidence of coverage to be issued to
7-30 the enrollees;
7-31 7. A copy of the form of the group contract, if any, which is to
7-32 be issued to employers, unions, trustees or other organizations;
7-33 8. Certified financial statements showing the applicant’s assets,
7-34 liabilities and sources of financial support;
7-35 9. The proposed method of marketing the plan, a financial plan
7-36 which includes a [three-year] 3-year projection of the initial
7-37 operating results anticipated and the sources of working capital [as
7-38 well as] and any other sources of funding;
7-39 10. A power of attorney , [duly] executed by the applicant,
7-40 appointing the Commissioner and his [duly] authorized deputies[,]
7-41 as the true and lawful attorney of such applicant in and for this state
7-42 upon whom all lawful process in any legal action or proceeding
7-43 against the health maintenance organization on a cause of action
7-44 arising in this state may be served;
7-45 11. A statement reasonably describing the geographic area to
7-46 be served;
8-1 12. A description of the [complaint] procedures for resolving
8-2 complaints and procedures for external reviews to be [utilized]
8-3 used as required under NRS 695C.260;
8-4 13. A description of the procedures and programs to be
8-5 implemented to meet the quality of health care requirements in
8-6 NRS 695C.080;
8-7 14. A description of the mechanism by which enrollees will be
8-8 afforded an opportunity to participate in matters of program content
8-9 under subsection 2 of NRS 695C.110; and
8-10 15. Such other information as the Commissioner may require
8-11 to make the determinations required in NRS 695C.080.
8-12 Sec. 12. NRS 695C.260 is hereby amended to read as follows:
8-13 695C.260 [Every] Each health maintenance organization shall
8-14 establish [a complaint] :
8-15 1. A system for resolving complaints which complies with the
8-16 provisions of NRS 695G.200 to 695G.230, inclusive[.] ; and
8-17 2. A system for conducting external reviews of final adverse
8-18 determinations that complies with the provisions of sections 16 to
8-19 28, inclusive, of this act.
8-20 Sec. 13. NRS 695C.330 is hereby amended to read as follows:
8-21 695C.330 1. The Commissioner may suspend or revoke any
8-22 certificate of authority issued to a health maintenance organization
8-23 pursuant to the provisions of this chapter if he finds that any of the
8-24 following conditions exist:
8-25 (a) The health maintenance organization is operating
8-26 significantly in contravention of its basic organizational document,
8-27 its health care plan or in a manner contrary to that described in and
8-28 reasonably inferred from any other information submitted pursuant
8-29 to NRS 695C.060, 695C.070 and 695C.140, unless any amendments
8-30 to those submissions have been filed with and approved by the
8-31 Commissioner;
8-32 (b) The health maintenance organization issues evidence of
8-33 coverage or uses a schedule of charges for health care services
8-34 which do not comply with the requirements of NRS [695C.170 to
8-35 695C.200, inclusive, or 695C.1694, 695C.1695] 695C.1694 to
8-36 695C.200; inclusive, or 695C.207;
8-37 (c) The health care plan does not furnish comprehensive health
8-38 care services as provided for in NRS 695C.060;
8-39 (d) The State Board of Health certifies to the Commissioner that
8-40 the health maintenance organization:
8-41 (1) Does not meet the requirements of subsection 2 of NRS
8-42 695C.080; or
8-43 (2) Is unable to fulfill its obligations to furnish health care
8-44 services as required under its health care plan;
9-1 (e) The health maintenance organization is no longer financially
9-2 responsible and may reasonably be expected to be unable to meet its
9-3 obligations to enrollees or prospective enrollees;
9-4 (f) The health maintenance organization has failed to put into
9-5 effect a mechanism affording the enrollees an opportunity to
9-6 participate in matters relating to the content of programs pursuant to
9-7 NRS 695C.110;
9-8 (g) The health maintenance organization has failed to put into
9-9 effect the system [for complaints] required by NRS 695C.260 for:
9-10 (1) Resolving complaints in a manner reasonably to dispose
9-11 of valid complaints; and
9-12 (2) Conducting external reviews of final adverse
9-13 determinations that comply with the provisions of sections 16 to
9-14 28, inclusive, of this act;
9-15 (h) The health maintenance organization or any person on its
9-16 behalf has advertised or merchandised its services in an untrue,
9-17 misrepresentative, misleading, deceptive or unfair manner;
9-18 (i) The continued operation of the health maintenance
9-19 organization would be hazardous to its enrollees; or
9-20 (j) The health maintenance organization has otherwise failed to
9-21 comply substantially with the provisions of this chapter.
9-22 2. A certificate of authority must be suspended or revoked only
9-23 after compliance with the requirements of NRS 695C.340.
9-24 3. If the certificate of authority of a health maintenance
9-25 organization is suspended, the health maintenance organization shall
9-26 not, during the period of that suspension, enroll any additional
9-27 groups or new individual contracts, unless those groups or persons
9-28 were contracted for before the date of suspension.
9-29 4. If the certificate of authority of a health maintenance
9-30 organization is revoked, the organization shall proceed, immediately
9-31 following the effective date of the order of revocation, to wind up its
9-32 affairs and shall conduct no further business except as may be
9-33 essential to the orderly conclusion of the affairs of the organization.
9-34 It shall engage in no further advertising or solicitation of any kind.
9-35 The Commissioner may by written order permit such further
9-36 operation of the organization as he may find to be in the best interest
9-37 of enrollees to the end that enrollees are afforded the greatest
9-38 practical opportunity to obtain continuing coverage for health care.
9-39 Sec. 14. NRS 695F.230 is hereby amended to read as follows:
9-40 695F.230 1. Each prepaid limited health service organization
9-41 shall establish a system for the resolution of written complaints
9-42 submitted by enrollees and providers.
9-43 2. The provisions of subsection 1 do not prohibit an enrollee or
9-44 provider from filing a complaint with the Commissioner or limit the
9-45 Commissioner’s authority to investigate such a complaint.
10-1 3. Each prepaid limited health service organization that
10-2 issues any evidence of coverage that provides, delivers, arranges
10-3 for, pays for or reimburses any cost of health care services
10-4 through managed care shall provide a system for resolving any
10-5 complaints of an enrollee or subscriber concerning those health
10-6 care services that complies with the provisions of sections 16 to 28,
10-7 inclusive, of this act and NRS 695G.200 to 695G.230, inclusive.
10-8 Sec. 15. Chapter 695G of NRS is hereby amended by adding
10-9 thereto the provisions set forth as sections 16 to 28, inclusive, of this
10-10 act.
10-11 Sec. 16. “Adverse determination” means a determination of
10-12 a managed care organization to deny all or part of a service or
10-13 procedure that is proposed or being provided to an insured on the
10-14 basis that it is not medically necessary or appropriate or is
10-15 experimental or investigational. The term does not include a
10-16 determination of a managed care organization that such an
10-17 allocation is not a covered benefit.
10-18 Sec. 17. “Authorized representative” means a person who
10-19 has obtained the consent of an insured to represent him in an
10-20 external review of a final adverse determination conducted
10-21 pursuant to sections 16 to 28, inclusive, of this act.
10-22 Sec. 18. “Clinical peer” means a physician who is:
10-23 1. Engaged in the practice of medicine; and
10-24 2. Certified or is eligible for certification by a member board
10-25 of the American Board of Medical Specialties in the same or
10-26 similar area of practice as is the health care service that is the
10-27 subject of a final adverse determination.
10-28 Sec. 19. “External review organization” means an
10-29 organization that:
10-30 1. Conducts an external review of a final adverse
10-31 determination; and
10-32 2. Is certified by the Commissioner in accordance with
10-33 section 2 of this act.
10-34 Sec. 20. “Medically necessary” means health care services or
10-35 products that a prudent physician would provide to a patient to
10-36 prevent, diagnose or treat an illness, injury or disease or any
10-37 symptoms thereof that are necessary and:
10-38 1. Provided in accordance with generally accepted standards
10-39 of medical practice;
10-40 2. Clinically appropriate with regard to type, frequency,
10-41 extent, location and duration;
10-42 3. Not primarily provided for the convenience of the patient,
10-43 physician or other provider of health care;
10-44 4. Required to improve a specific health condition of an
10-45 insured or to preserve his existing state of health; and
11-1 5. The most clinically appropriate level of health care that
11-2 may be safely provided to the insured.
11-3 Sec. 21. 1. For the purposes of sections 16 to 28, inclusive,
11-4 of this act and NRS 695G.200 to 695G.230, inclusive, an adverse
11-5 determination is final if the insured has exhausted all procedures
11-6 set forth in the health care plan for reviewing the adverse
11-7 determination within the managed care organization.
11-8 2. An adverse determination shall be deemed final for the
11-9 purpose of submitting the adverse determination to an external
11-10 review organization for an external review:
11-11 (a) If an insured exhausts all procedures set forth in the health
11-12 care plan for reviewing the adverse determination within the
11-13 managed care organization and the managed care organization
11-14 fails to render a decision within the period required to render that
11-15 decision set forth in the health care plan; or
11-16 (b) If the managed care organization submits the adverse
11-17 determination to the external review organization without
11-18 requiring the insured to exhaust all procedures set forth in the
11-19 health care plan for reviewing the adverse determination within
11-20 the managed care organization.
11-21 Sec. 22. 1. If an insured or a physician of an insured
11-22 receives notice of a final adverse determination from a managed
11-23 care organization concerning the insured, and if the insured is
11-24 required to pay $500 or more for the health care services that are
11-25 the subject of the final adverse determination, the insured, the
11-26 physician of the insured or an authorized representative may,
11-27 within 60 days after receiving notice of the final adverse
11-28 determination, submit a request to the managed care organization
11-29 for an external review of the final adverse determination.
11-30 2. Within 5 days after receiving a request pursuant to
11-31 subsection 1, the managed care organization shall notify the
11-32 insured, his authorized representative or his physician, the agent
11-33 who performed utilization review for the managed care
11-34 organization, if any, and the Office for Consumer Health
11-35 Assistance that the request has been filed with the managed care
11-36 organization.
11-37 3. As soon as practicable after receiving a notice pursuant to
11-38 subsection 2, the Office for Consumer Health Assistance shall
11-39 assign an external review organization from the list maintained
11-40 pursuant to section 2 of this act. Each assignment made pursuant
11-41 to this subsection must be completed on a rotating basis.
11-42 4. Within 5 days after receiving notification from the Office
11-43 for Consumer Health Assistance specifying the external review
11-44 organization assigned pursuant to subsection 3, the managed care
11-45 organization shall provide to the external review organization all
12-1 documents and materials relating to the final adverse
12-2 determination, including, without limitation:
12-3 (a) Any medical records of the insured relating to the external
12-4 review;
12-5 (b) A copy of the provisions of the health care plan upon
12-6 which the final adverse determination was based;
12-7 (c) Any documents used by the managed care organization to
12-8 make the final adverse determination;
12-9 (d) The reasons for the final adverse determination; and
12-10 (e) Insofar as practicable, a list that specifies each provider of
12-11 health care who has provided health care to the insured and the
12-12 medical records of the provider of health care relating to the
12-13 external review.
12-14 Sec. 23. 1. Except as otherwise provided in section 24 of
12-15 this act, upon receipt of a request for an external review pursuant
12-16 to section 22 of this act, the external review organization shall,
12-17 within 5 days after receiving the request:
12-18 (a) Review the request and the documents and materials
12-19 submitted pursuant to section 22 of this act; and
12-20 (b) Notify the insured, his physician and the managed care
12-21 organization if any additional information is required to conduct a
12-22 review of the final adverse determination.
12-23 2. Except as otherwise provided in section 24 of this act, the
12-24 external review organization shall approve, modify or reverse
12-25 the final adverse determination within 15 days after it receives the
12-26 information required to make that determination pursuant to this
12-27 section. The external review organization shall submit a copy of its
12-28 determination, including the reasons therefor, to:
12-29 (a) The insured;
12-30 (b) The physician of the insured;
12-31 (c) The authorized representative of the insured, if any; and
12-32 (d) The managed care organization.
12-33 Sec. 24. 1. A managed care organization shall approve or
12-34 deny a request for an external review of a final adverse
12-35 determination in an expedited manner not later than 72 hours
12-36 after it receives proof from the insured’s provider of health care
12-37 that failure to proceed in an expedited manner may jeopardize the
12-38 life or health of the insured.
12-39 2. If a managed care organization approves a request for an
12-40 external review pursuant to subsection 1, the managed care
12-41 organization shall:
12-42 (a) In accordance with subsections 4 and 5, assign the request
12-43 to an external review organization not later than 1 working day
12-44 after approving the request; and
13-1 (b) At the time of assigning the request, provide to the external
13-2 review organization all documents and materials specified in
13-3 subsection 4 of section 22 of this act.
13-4 3. An external review organization that is assigned to conduct
13-5 an external review pursuant to subsection 2 shall, if it accepts the
13-6 assignment:
13-7 (a) Complete its external review not later than 2 working days
13-8 after receiving the assignment, unless the insured and the
13-9 managed care organization agree to a longer period;
13-10 (b) Not later than 1 working day after completing its external
13-11 review, notify the insured, the physician of the insured, the
13-12 authorized representative of the insured, if any, and the managed
13-13 care organization by telephone of its determination; and
13-14 (c) Not later than 5 working days after completing its external
13-15 review, submit a written decision of its external review to the
13-16 insured, the physician of the insured, the authorized representative
13-17 of the insured, if any, and the managed care organization.
13-18 4. At least once each month, the Office for Consumer Health
13-19 Assistance shall designate at least 2 external review organizations
13-20 to conduct external reviews in an expedited manner pursuant to
13-21 this section. As soon as practicable after designating an external
13-22 review organization pursuant to this section, the Office for
13-23 Consumer Health Assistance shall notify each managed care
13-24 organization of the designation.
13-25 5. As soon as practicable after assigning an external review
13-26 organization to conduct an external review pursuant to this
13-27 section, the managed care organization shall notify the Office for
13-28 Consumer Health Assistance of the assignment. Each assignment
13-29 made by a managed care organization pursuant to this section
13-30 must be completed on a rotating basis.
13-31 Sec. 25. The decision of an external review organization
13-32 concerning a request for an external review must be based on:
13-33 1. Documentary evidence, including any recommendation of
13-34 the physician of the insured submitted pursuant to section 22 of
13-35 this act;
13-36 2. Medical evidence, including, without limitation:
13-37 (a) Professional standards of safety and effectiveness for
13-38 diagnosis, care and treatment that are generally recognized in the
13-39 United States;
13-40 (b) Any report published in literature that is peer-reviewed;
13-41 (c) Evidence-based medicine, including, without limitation,
13-42 reports and guidelines that are published by professional
13-43 organizations that are recognized nationally and that include
13-44 supporting scientific data; and
14-1 (d) An opinion of an independent physician who, as
14-2 determined by the external review organization, is an expert in the
14-3 health specialty that is the subject of the external review; and
14-4 3. The terms and conditions for benefits set forth in the
14-5 evidence of coverage issued to the insured by the managed care
14-6 organization.
14-7 Sec. 26. 1. If the determination of an external review
14-8 organization concerning an external review of a final adverse
14-9 determination is in favor of the insured, the determination is final,
14-10 conclusive and binding upon the managed care organization.
14-11 2. An external review organization or any clinical peer who
14-12 conducts or participates in an external review of a final adverse
14-13 determination for the external review organization is not liable in
14-14 a civil action for damages relating to a determination made by the
14-15 external review organization if the determination is made in good
14-16 faith and without gross negligence.
14-17 3. The cost of conducting an external review of a final
14-18 adverse determination pursuant to sections 16 to 28, inclusive, of
14-19 this act must be paid by the managed care organization that made
14-20 the final adverse determination.
14-21 Sec. 27. In lieu of resolving a complaint of an insured in
14-22 accordance with a system for resolving complaints established
14-23 pursuant to the provisions of NRS 695G.200, a managed care
14-24 organization may:
14-25 1. Submit the complaint to an external review organization
14-26 pursuant to the provisions of sections 16 to 28, inclusive, of this
14-27 act; or
14-28 2. If a federal law or regulation provides a procedure for
14-29 submitting the complaint for resolution that the Commissioner
14-30 determines is substantially similar to the procedure for submitting
14-31 the complaint to an external review organization pursuant to
14-32 sections 16 to 28, inclusive, of this act, submit the complaint for
14-33 resolution in accordance with the federal law or regulation.
14-34 Sec. 28. On or before January 31 of each year, each
14-35 managed care organization shall file a written report with the
14-36 Office for Consumer Health Assistance setting forth the total
14-37 number of:
14-38 1. Requests for external review that were received by the
14-39 managed care organization during the immediately preceding
14-40 year; and
14-41 2. Final adverse determinations of the managed care
14-42 organization that were:
14-43 (a) Upheld during the immediately preceding year.
14-44 (b) Reversed during the immediately preceding year.
15-1 Sec. 29. NRS 695G.010 is hereby amended to read as follows:
15-2 695G.010 As used in this chapter, unless the context otherwise
15-3 requires, the words and terms defined in NRS 695G.020 to
15-4 695G.080, inclusive, and sections 16 to 20, inclusive, of this act
15-5 have the meanings ascribed to them in those sections.
15-6 Sec. 30. NRS 695G.080 is hereby amended to read as follows:
15-7 695G.080 1. “Utilization review” means the various methods
15-8 that may be used by a managed care organization to review the
15-9 amount and appropriateness of the provision of a specific health
15-10 care service to an insured.
15-11 2. The term does not include an external review of a final
15-12 adverse determination conducted pursuant to sections 16 to 28,
15-13 inclusive, of this act.
15-14 Sec. 31. NRS 695G.090 is hereby amended to read as follows:
15-15 695G.090 1. The provisions of this chapter apply to each
15-16 organization and insurer that operates as a managed care
15-17 organization and may include, without limitation, an insurer that
15-18 issues a policy of health insurance, an insurer that issues a policy of
15-19 individual or group health insurance, a carrier serving small
15-20 employers, a fraternal benefit society, a hospital or medical service
15-21 corporation , and a health maintenance organization.
15-22 2. In addition to the provisions of this chapter, each managed
15-23 care organization shall comply with any other applicable provision
15-24 of this title.
15-25 3. The provisions of NRS 695G.200 to 695G.230, inclusive,
15-26 do not apply to an organization that provides health care services
15-27 through managed care to recipients of Medicaid under the State
15-28 Plan for Medicaid or insurance pursuant to the Children’s Health
15-29 Insurance Program pursuant to a contract with the Division of
15-30 Health Care Financing and Policy of the Department of Human
15-31 Resources. This subsection does not exempt a managed care
15-32 organization from any provision of this chapter for services
15-33 provided pursuant to any other contract.
15-34 Sec. 32. NRS 695G.210 is hereby amended to read as follows:
15-35 695G.210 1. [A] Except as otherwise provided in section 27
15-36 of this act, a system for resolving complaints created pursuant to
15-37 NRS 695G.200 must include, without limitation, an initial
15-38 investigation, a review of the complaint by a review board and a
15-39 procedure for appealing a determination regarding the complaint.
15-40 The majority of the members of the review board must be insureds
15-41 who receive health care services from the managed care
15-42 organization.
15-43 2. Except as otherwise provided in subsection 3, a review
15-44 board shall complete its review regarding a complaint or appeal and
15-45 notify the insured of its determination not later than 30 days after
16-1 the complaint or appeal is filed, unless the insured and the review
16-2 board have agreed to a longer period . [of time.]
16-3 3. If a complaint involves an imminent and serious threat to the
16-4 health of the insured, the managed care organization shall inform the
16-5 insured immediately of his right to an expedited review of his
16-6 complaint. If an expedited review is required, the review board shall
16-7 notify the insured in writing of its determination within 72 hours
16-8 after the complaint is filed.
16-9 4. Notice provided to an insured by a review board regarding a
16-10 complaint must include, without limitation, an explanation of any
16-11 further rights of the insured regarding the complaint that aGreen numbers along left margin indicate location on the printed bill (e.g., 5-15 indicates page 5, line 15).re
16-12 available under his health care plan.
16-13 Sec. 33. NRS 695G.230 is hereby amended to read as follows:
16-14 695G.230 1. [Following] After approval by the
16-15 Commissioner, each managed care organization shall provide a
16-16 written notice to an insured, in clear and comprehensible language
16-17 that is understandable to an ordinary layperson, explaining the right
16-18 of the insured to file a written complaint and to obtain an expedited
16-19 review pursuant to NRS 695G.210. Such a notice must be provided
16-20 to an insured:
16-21 (a) At the time he receives his certificate of coverage or
16-22 evidence of coverage;
16-23 (b) Any time that the managed care organization denies
16-24 coverage of a health care service or limits coverage of a health care
16-25 service to an insured; and
16-26 (c) Any other time deemed necessary by the Commissioner.
16-27 2. [Any time that] If a managed care organization denies
16-28 coverage of a health care service to an insured, including, without
16-29 limitation, a health maintenance organization that denies a claim
16-30 related to a health care plan pursuant to NRS 695C.185, it shall
16-31 notify the insured in writing within 10 working days after it denies
16-32 coverage of the health care service of:
16-33 (a) The reason for denying coverage of the service;
16-34 (b) The criteria by which the managed care organization or
16-35 insurer determines whether to authorize or deny coverage of the
16-36 health care service; [and]
16-37 (c) His right to [file] :
16-38 (1) File a written complaint and the procedure for filing such
16-39 a complaint[.] ;
16-40 (2) Appeal a final adverse determination pursuant to
16-41 sections 16 to 28, inclusive, of this act;
16-42 (3) Receive an expedited external review of a final adverse
16-43 determination if the managed care organization receives proof
16-44 from the insured’s provider of health care that failure to proceed
16-45 in an expedited manner may jeopardize the life or health of the
17-1 insured, including notification of the procedure for requesting the
17-2 expedited external review; and
17-3 (4) Receive assistance from any person, including an
17-4 attorney, for an external review of a final adverse determination;
17-5 and
17-6 (d) The telephone number of the Office for Consumer Health
17-7 Assistance.
17-8 3. A written notice which is approved by the Commissioner
17-9 shall be deemed to be in clear and comprehensible language that is
17-10 understandable to an ordinary layperson.
17-11 Sec. 34. NRS 223.580 is hereby amended to read as follows:
17-12 223.580 On or before February 1 of each year, the Director
17-13 shall submit a written report to the Governor, and to the Director of
17-14 the Legislative Counsel Bureau for transmittal to the appropriate
17-15 committee or committees of the Legislature. The report must
17-16 include, without limitation:
17-17 1. A statement setting forth the number and geographic origin
17-18 of the written and telephonic inquiries received by the office and the
17-19 issues to which those inquiries were related;
17-20 2. A statement setting forth the type of assistance provided to
17-21 each consumer and injured employee who sought assistance from
17-22 the Director, including, without limitation, the number of referrals
17-23 made to the Attorney General pursuant to subsection 7 of NRS
17-24 223.560; [and]
17-25 3. A statement setting forth the disposition of each inquiry and
17-26 complaint received by the Director[.] ; and
17-27 4. A statement setting forth the number of external reviews
17-28 conducted by external review organizations pursuant to sections
17-29 16 to 28, inclusive, of this act and the disposition of each of those
17-30 reviews as reported pursuant to section 28 of this act.
17-31 Sec. 35. NRS 287.04335 is hereby amended to read as
17-32 follows:
17-33 287.04335 If the Board provides health insurance through a
17-34 plan of self-insurance, it shall comply with the provisions of
17-35 sections 16 to 28, inclusive, of this act and NRS 689B.255,
17-36 695G.150, 695G.160, 695G.170 and 695G.200 to 695G.230,
17-37 inclusive,in the same manner as an insurer that is licensed pursuant
17-38 to title 57 of NRS is required to comply with those provisions.
17-39 Sec. 36. NRS 422.273 is hereby amended to read as follows:
17-40 422.273 1. For any Medicaid managed care program
17-41 established in the State of Nevada, the Department shall contract
17-42 only with a health maintenance organization that has:
17-43 (a) Negotiated in good faith with a federally-qualified health
17-44 center to provide health care services for the health maintenance
17-45 organization;
18-1 (b) Negotiated in good faith with the University Medical Center
18-2 of Southern Nevada to provide inpatient and ambulatory services to
18-3 recipients of Medicaid; and
18-4 (c) Negotiated in good faith with the University of Nevada
18-5 School of Medicine to provide health care services to recipients of
18-6 Medicaid.
18-7 Nothing in this section shall be construed as exempting a federally-
18-8 qualified health center, the University Medical Center of Southern
18-9 Nevada or the University of Nevada School of Medicine from the
18-10 requirements for contracting with the health maintenance
18-11 organization.
18-12 2. During the development and implementation of any
18-13 Medicaid managed care program, the Department shall cooperate
18-14 with the University of Nevada School of Medicine by assisting in
18-15 the provision of an adequate and diverse group of patients upon
18-16 which the school may base its educational programs.
18-17 3. The University of Nevada School of Medicine may establish
18-18 a nonprofit organization to assist in any research necessary for the
18-19 development of a Medicaid managed care program, receive and
18-20 accept gifts, grants and donations to support such a program and
18-21 assist in establishing educational services about the program for
18-22 recipients of Medicaid.
18-23 4. For the purpose of contracting with a Medicaid managed
18-24 care program pursuant to this section, a health maintenance
18-25 organization is exempt from the provisions of NRS 695C.123.
18-26 5. The provisions of this section apply to any managed care
18-27 organization, including a health maintenance organization, that
18-28 provides health care services to recipients of Medicaid under the
18-29 State Plan for Medicaid or the Children’s Health Insurance
18-30 Program pursuant to a contract with the Division of Health Care
18-31 Financing and Policy of the Department of Human Resources.
18-32 Such a managed care organization or health maintenance
18-33 organization is not required to establish a system for conducting
18-34 external reviews of final adverse determinations in accordance
18-35 with chapter 695B, 695C or 695G of NRS. This subsection does
18-36 not exempt such a managed care organization or health
18-37 maintenance organization for services provided pursuant to any
18-38 other contract.
18-39 6. As used in this section, unless the context otherwise
18-40 requires:
18-41 (a) “Federally-qualified health center” has the meaning ascribed
18-42 to it in 42 U.S.C. § 1396d(l)(2)(B).
18-43 (b) “Health maintenance organization” has the meaning ascribed
18-44 to it in NRS 695C.030.
18-45 (c) “Managed care organization” has the meaning ascribed to
18-46 it in NRS 695G.050.
19-1 Sec. 37. 1. This section becomes effective upon passage and
19-2 approval.
19-3 2. Sections 1 to 36, inclusive, of this act become effective:
19-4 (a) Upon passage and approval for the purposes of:
19-5 (1) Adopting regulations by the Commissioner of Insurance
19-6 to carry out the provisions of this act; and
19-7 (2) Certifying external review organizations pursuant to
19-8 section 2 of this act;
19-9 (b) On January 1, 2004, for the purposes of filing notice of and
19-10 approving any material modifications to operations as required
19-11 pursuant to NRS 695C.140; and
19-12 (c) On July 1, 2004, for all other purposes.
19-13 20~~~~~03