NRS 695G.340 Approval or denial; payment of claim and interest; request for additional information; award of costs and attorney’s fees; compliance with requirements; imposition of administrative fine or suspension or revocation of certificate of authority for failure to comply; report of compliance by organization.

779 words·~4 min read·/nv/chapter-695g-managed-care/695g-340

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1. Except as otherwise provided in subsection 2 and NRS 439B.754 , a managed care organization shall approve or deny a claim within 21 days after the managed care organization receives the claim, if the claim is submitted electronically, or 30 days after the managed care organization receives the claim, if the claim is not submitted electronically. If the claim is approved, the managed care organization shall also pay the claim within that period. Except as otherwise provided in this section, if the approved claim is not paid within that period, the managed care organization shall pay interest on the claim at a rate of 10 percent per annum.

The interest must be calculated from the date on which payment of the claim is due pursuant to this subsection until the date on which the claim is paid.

2. If the managed care organization requires additional information to determine whether to approve or deny the claim, it shall notify the claimant of its request for the additional information within 20 working days after it receives the claim. The managed care organization shall notify the claimant of all the specific reasons for the delay in approving or denying the claim. The managed care organization shall approve or deny the claim within 21 days after receiving the additional information, if the additional information is submitted electronically, or 30 days after receiving the additional information, if the additional information is not submitted electronically.

If the claim is approved, the managed care organization shall also pay the claim within that period. If the approved claim is not paid within that period, the managed care organization shall pay interest on the claim in the manner prescribed in subsection 1.

3. A managed care organization shall not:

(a)Deny a claim without a reasonable basis for the denial.

(b)Request a claimant to resubmit information that the claimant has already provided to the managed care organization, unless the managed care organization provides a legitimate reason for the request and the purpose of the request is not to delay the payment of the claim, harass the claimant or discourage the filing of claims.

4. A managed care organization shall not pay only part of a claim that has been approved and is fully payable.

5. A court shall award costs and reasonable attorney’s fees to the prevailing party in an action brought pursuant to this section.

6. The payment of interest provided for in this section for the late payment of an approved claim may be waived only if the payment was delayed because of an act of God or another cause beyond the control of the managed care organization.

7. The Commissioner may require a managed care organization to provide evidence which demonstrates that the managed care organization has substantially complied with the requirements set forth in this section, including, without limitation, payment within the time periods specified by this section of at least 95 percent of approved claims or at least 90 percent of the total dollar amount for approved claims.

8. If the Commissioner determines that a managed care organization is not in substantial compliance with the requirements set forth in this section or has failed to approve or deny a claim or pay an approved claim within 60 working days after receiving the claim, the Commissioner may require the managed care organization to pay an administrative fine in an amount to be determined by the Commissioner. Upon a second or subsequent determination that a managed care organization is not in substantial compliance with the requirements set forth in this section or has failed to approve or deny a claim or pay an approved claim within 60 working days after receiving the claim, the Commissioner may suspend or revoke the certificate of authority of the managed care organization.

9. On or before February 1 of each year, a managed care organization shall submit to the Commissioner a report concerning the compliance of the managed care organization with the requirements of this section during the immediately preceding calendar year. The report must include, without limitation:

(a)The number of claims for which the managed care organization failed to comply with the requirements of subsections 1 and 2 during the immediately preceding calendar year; and

(b)The total amount of interest paid by the managed care organization pursuant to subsections 1 and 2 during the immediately preceding calendar year.

PROHIBITED ACTS