NRS 695G.230 Written notice required by carrier to insured explaining rights of insureds regarding decision to deny coverage; written notice to insured when health carrier denies coverage of health care service.

707 words·~3 min read·/nv/chapter-695g-managed-care/695g-230

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

1. After approval by the Commissioner, each health carrier shall provide a 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 written complaint and to obtain an expedited review pursuant to NRS 695G.210 . Such a notice must be provided to an insured:

(a)At the time the insured receives his or her certificate of coverage or evidence of coverage;

(b)Any time that the health carrier 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. If a health carrier denies coverage of a health care service to an insured, including, without limitation, a managed care organization that denies a claim related to a health care plan pursuant to NRS 695G.340 , it shall notify the insured and, if applicable, the provider of health care who submitted the claim, in writing within:

(a)Twenty-one days after the health carrier receives all information necessary to make a determination concerning the claim, if the information is submitted electronically;

(b)Thirty days after the health carrier receives all information necessary to make a determination concerning the claim, if the information is not submitted electronically; or

(c)If no claim is received, within 10 working days after the health carrier denies coverage of the health care service.

3. The notice required pursuant to subsection 2 must include, without limitation:

(a)All reasons for denying coverage of the service, including, without limitation, the specific facts and provisions of the plan relied upon by the health carrier as a basis to deny coverage of the service;

(b)The criteria by which the health carrier or insurer determines whether to authorize or deny coverage of the health care service and a description of the manner in which the health carrier applied those criteria to the health care service;

(c)A summary of any applicable process established pursuant to NRS 687B.820 for challenging the denial of the claim;

(d)The right of the insured to:

(1)File a written complaint and the procedure for filing such a complaint;

(2)Appeal an adverse determination pursuant to NRS 695G.241 to 695G.310 , inclusive;

(3)Receive an expedited external review of an adverse determination if the health carrier receives proof from the insured’s provider of health care that failure to proceed in an expedited manner may jeopardize the life or health of the insured, including notification of the procedure for requesting the expedited external review; and

(4)Receive assistance from any person, including an attorney, for an external review of an adverse determination; and

(e)The telephone number of the Office for Consumer Health Assistance.

4. A written notice which is approved by the Commissioner pursuant to subsection 1 shall be deemed to be in clear and comprehensible language that is understandable to an ordinary layperson.

5. If a health carrier denies a claim submitted by a provider of health care, the health carrier shall notify the provider of health care in writing of the denial within:

(a)Twenty-one days after the health carrier receives all information necessary to make a determination concerning the claim, if the information is submitted electronically; or

(b)Thirty days after the health carrier receives all information necessary to make a determination concerning the claim, if the information is not submitted electronically.

6. The notice required pursuant to subsection 5 must include, without limitation:

(a)All reasons for denying the claim, including, without limitation, the specific facts and provisions of the plan relied upon by the health carrier as a basis to deny coverage of the service;

(b)The criteria by which the health carrier determines whether to approve or deny the claim and a description of the manner in which the health carrier applied those criteria to the claim; and

(c)A summary of any applicable process established pursuant to NRS 687B.820 for challenging the denial of the claim.

EXTERNAL REVIEW OF ADVERSE DETERMINATION