reglab/housing_qa huggingface dataset:
NV Rev Stat § 695G.210 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.210 - Review board; appeal; right to expedited review of complaint; notice to insured.

  1. Except as otherwise provided in NRS 695G.300, a system for resolving complaints created pursuant to NRS 695G.200 must include, without limitation, an initial investigation, a review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members of the review board must be insureds who receive health care services from the managed care organization.  2. Except as otherwise provided in subsection 3, a review board shall complete its review regarding a complaint or appeal and notify the insured of its determination not later than 30 days after the complaint or appeal is filed, unless the insured and the review board have agreed to a longer period.  3. If a complaint involves an imminent and serious threat to the health of the insured, the managed care organization shall inform the insured immediately of the right of the insured to an expedited review of the insured’s complaint. If an expedited review is required, the review board shall notify the insured in writing of its determination within 72 hours after the complaint is filed.  4. Notice provided to an insured by a review board regarding a complaint must include, without limitation, an explanation of any further rights of the insured regarding the complaint that are available under the health care plan of the insured.  (Added to NRS by 1997, 306; A 2003, 783)
NV Rev Stat § 695G.220 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.220 - Annual report; managed care organization to maintain records of complaints concerning something other than health care services.

  1. Each managed care organization shall submit to the Commissioner an annual report regarding its system for resolving complaints established pursuant to NRS 695G.200 on a form prescribed by the Commissioner which includes, without limitation:  (a) A description of the procedures used for resolving 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 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.  (Added to NRS by 1997, 306; A 2013, 3655; 2017, 2402)
NV Rev Stat § 695G.230 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.230 - Written notice to insured explaining rights of insureds regarding decision to deny coverage; notice to insured when health carrier denies coverage of health care service.

  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 health maintenance organization that denies a claim related to a health care plan pursuant to NRS 695C.185, it shall notify the insured in writing within 10 working days after it denies coverage of the health care service of:  (a) The reason for denying 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;  (c) 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  (d) The telephone number of the Office for Consumer Health Assistance.  3. A written notice which is approved by the Commissioner shall be deemed to be in clear and comprehensible language that is understandable to an ordinary layperson.  (Added to NRS by 1997, 307; A 1999, 3097; 2003, 784; 2011, 3411)
NV Rev Stat § 695G.241 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.241 - External review of adverse determination.

 Except as otherwise required for an expedited external review pursuant to NRS 695G.271 or 695G.275, for the purposes of NRS 695G.200 to 695G.310, inclusive, an adverse determination may be subject to an external review:  1. If a covered person exhausts all procedures set forth in the health care plan for reviewing the adverse determination within the health carrier and the health carrier fails to render a decision within the period required to render that decision set forth in the health care plan; or  2. If the health carrier allows the covered person to submit the adverse determination to the independent review organization without requiring the covered person to exhaust all procedures set forth in the health care plan for reviewing the adverse determination within the health carrier.  (Added to NRS by 2003, 780; A 2011, 3412)
NV Rev Stat § 695G.243 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.243 - Applicability.

  1. Except as otherwise provided in subsection 2, the provisions of NRS 695G.200 to 695G.310, inclusive, apply to all health carriers.  2. The provisions of subsection 1 do not apply to:  (a) A policy or certificate that provides only coverage for:  (1) A specified disease or accident;  (2) Accidents;  (3) Credit;  (4) Dental;  (5) Disability income;  (6) Hospital indemnity;  (7) Long-term care insurance;  (8) Vision care; or  (9) Any other limited supplemental benefit;  (b) A Medicare supplement policy of insurance, as defined in regulations adopted by the Commissioner;  (c) Coverage under a plan through Medicare, Medicaid or the Federal Employees Health Benefits Program, FEHBP, 5 U.S.C. §§ 8901 et seq.;  (d) Any coverage issued under the Civilian Health and Medical Program of the Uniformed Services, CHAMPUS, 10 U.S.C. §§ 1071 et seq., and any coverage issued as supplemental to that coverage;  (e) Any coverage issued as supplemental to liability insurance;  (f) Workers’ compensation or similar insurance;  (g) Automobile medical payment insurance; or  (h) Any insurance under which benefits are payable with or without regard to fault, whether written on a group, blanket or individual basis.  (Added to NRS by 2011, 3399)
NV Rev Stat § 695G.247 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.247 - Requests for external review to be in writing; exception; form and content.

  1. Except for a request for an expedited external review as set forth in NRS 695G.271 or 695G.275, all requests for external review must be made in writing to the Office for Consumer Health Assistance.  2. The Commissioner may prescribe by regulation the form and content of requests for external review required to be submitted pursuant to this section.  3. A covered person or the covered person’s authorized representative may submit a request for an external review of an adverse determination.  (Added to NRS by 2011, 3401)
NV Rev Stat § 695G.251 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.251 - Request for review; assignment of independent review organization; provision of documents relating to adverse determination to independent review organization.

  1. If a covered person or a physician of a covered person receives notice of an adverse determination from a health carrier concerning the covered person, the covered person, the physician of the covered person or an authorized representative may, within 4 months after receiving notice of the adverse determination, submit a request to the Office for Consumer Health Assistance for an external review of the adverse determination.  2. Within 5 days after receiving a request pursuant to subsection 1, the Office for Consumer Health Assistance shall notify the covered person, the authorized representative or physician of the covered person, the agent who performed utilization review for the health carrier, if any, and the health carrier that the request has been filed with the Office for Consumer Health Assistance.  3. As soon as practicable after receiving a request pursuant to subsection 1, the Office for Consumer Health Assistance shall assign an independent review organization from the list maintained pursuant to NRS 683A.3715. Each assignment made pursuant to this subsection must be completed on a rotating basis.  4. Within 5 days after receiving notification from the Office for Consumer Health Assistance specifying the independent review organization assigned pursuant to subsection 3, the health carrier shall provide to the independent review organization all documents and materials relating to the adverse determination, including, without limitation:  (a) Any medical records of the insured relating to the external review;  (b) A copy of the provisions of the health benefit plan upon which the adverse determination was based;  (c) Any documents used by the health carrier to make the adverse determination;  (d) The reasons for the adverse determination; and  (e) Insofar as practicable, a list that specifies each provider of health care who has provided health care to the covered person and the medical records of the provider of health care relating to the external review.  (Added to NRS by 2003, 780; A 2011, 3412)
NV Rev Stat § 695G.261 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.261 - Review of documents by independent review organization; decision of independent review organization.

  1. Except as otherwise provided in NRS 695G.271 and 695G.275, upon receipt of a request for an external review pursuant to NRS 695G.251, the independent review organization shall, within 5 days after receiving the request:  (a) Review the request and the documents and materials submitted pursuant to NRS 695G.251; and  (b) Notify the covered person, the physician of the covered person and the health carrier if any additional information is required to conduct a review of the adverse determination. Such additional information must be provided within 5 days after receiving notice that the information is required to conduct a review of the adverse determination. The independent review organization shall forward to the health carrier, within 1 business day after receipt, any information received from a covered person or the physician of a covered person.  2. Except as otherwise provided in NRS 695G.271 and 695G.275, the independent review organization shall approve, modify or reverse the adverse determination within 15 days after it receives the information required to make that determination pursuant to this section. The independent review organization shall submit a copy of its determination, including the reasons therefor, to:  (a) The covered person;  (b) The physician of the covered person;  (c) The authorized representative of the covered person, if any; and  (d) The health carrier.  (Added to NRS by 2003, 781; A 2011, 3413)
NV Rev Stat § 695G.271 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.271 - Expedited approval or denial of request.

  1. The Office for Consumer Health Assistance shall approve or deny a request for an external review of an adverse determination in an expedited manner not later than 72 hours after it receives proof from the provider of health care of the covered person that:  (a) The adverse determination concerns an admission, availability of care, continued stay or health care service for which the covered person received emergency services but has not been discharged from the facility providing the services or care; or  (b) Failure to proceed in an expedited manner may jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function.  2. If the Office for Consumer Health Assistance approves a request for an external review pursuant to subsection 1, the Office for Consumer Health Assistance shall assign the request to an independent review organization not later than 1 working day after approving the request. Each assignment made by the Office for Consumer Health Assistance pursuant to this section must be completed on a rotating basis.  3. Within 24 hours after receiving notice of the Officer for Consumer Health Assistance assigning the request, the health carrier shall provide to the independent review organization all documents and materials specified in subsection 4 of NRS 695G.251.  4. An independent review organization that is assigned to conduct an external review pursuant to subsection 2 shall, if it accepts the assignment:  (a) Complete its external review not later than 48 hours after receiving the assignment, unless the covered person and the health carrier agree to a longer period;  (b) Not later than 24 hours after completing its external review, notify the covered person, the physician of the covered person, the authorized representative, if any, and the health carrier by telephone of its determination; and  (c) Not later than 48 hours after completing its external review, submit a written decision of its external review to the covered person, the physician of the covered person, the authorized representative, if any, and the health carrier.  (Added to NRS by 2003, 781; A 2011, 3413)
NV Rev Stat § 695G.280 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.280 - Basis for decision of independent review organization.

The decision of an independent review organization concerning a request for an external review must be based on:  1. Documentary evidence, including any recommendation of the physician of the insured submitted pursuant to NRS 695G.251;  2. Medical or scientific evidence, including, without limitation:  (a) Professional standards of safety and effectiveness for diagnosis, care and treatment that are generally recognized in the United States;  (b) Any report published in literature that is peer-reviewed;  (c) Evidence-based medicine, including, without limitation, reports and guidelines that are published by professional organizations that are recognized nationally and that include supporting scientific data; and  (d) An opinion of an independent physician who, as determined by the independent review organization, is an expert in the health specialty that is the subject of the independent review; and  3. The terms and conditions for benefits set forth in the evidence of coverage issued to the insured by the health carrier.  (Added to NRS by 2003, 782; A 2011, 3414)
NV Rev Stat § 695G.290 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.290 - Decision in favor of covered person binding on health carrier; limitation of liability; cost for independent review organization.

  1. If the determination of an independent review organization concerning an external review of an adverse determination is in favor of the covered person, the determination is final, conclusive and binding upon the health carrier.  2. An independent review organization or any clinical peer who conducts or participates in an external review of an adverse determination for the independent review organization is not liable in a civil action for damages relating to a determination made by the independent review organization if the determination is made in good faith and without gross negligence.  3. The cost of conducting an external review of an adverse determination pursuant to NRS 695G.241 to 695G.310, inclusive, must be paid by the health carrier that made the adverse determination.  (Added to NRS by 2003, 782; A 2011, 3415)
NV Rev Stat § 695G.300 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.300 - Submission of complaint of covered person to independent review organization.

In lieu of resolving a complaint of a covered person in accordance with a system for resolving complaints established pursuant to the provisions of NRS 695G.200, a health carrier may:  1. Submit the complaint to an independent review organization pursuant to the provisions of NRS 695G.241 to 695G.310, inclusive; or  2. If a federal law or regulation provides a procedure for submitting the complaint for resolution that the Commissioner determines is substantially similar to the procedure for submitting the complaint to an independent review organization pursuant to NRS 695G.241 to 695G.310, inclusive, submit the complaint for resolution in accordance with the federal law or regulation.  (Added to NRS by 2003, 782; A 2011, 3415)
NV Rev Stat § 695G.303 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.303 - Independent review organization and health carrier to maintain written records; submission of report upon request.

  1. An independent review organization assigned pursuant to NRS 695G.251, 695G.271 or 695G.275 to conduct an external review shall maintain written records, aggregated for each state and for each health carrier, on all requests for which it conducted an external review during a calendar year and, upon request, submit a report to the Office for Consumer Health Assistance in a format specified by the Commissioner.  2. The report must include, aggregated for each state and for each health carrier:  (a) The total number of requests for external review;  (b) The number of requests for external review resolved and, of those resolved, the number upholding the adverse determination and the number reversing the adverse determination;  (c) The average length of time for resolution;  (d) A summary of the types of coverages or cases for which an external review was sought;  (e) The number of external reviews that were terminated as the result of a reconsideration by the health carrier of its adverse determination after receipt of additional information from the covered person or the covered person’s authorized representative pursuant to subsection 4 of NRS 695G.251 and subsection 32 of NRS 695G.275; and  (f) Any other information the Office for Consumer Health Assistance may request or require.  3. An independent review organization shall retain the written records required pursuant to this section for at least 3 years.  4. Each health carrier shall maintain written records, aggregated for each state and for each type of health benefit plan offered by the health carrier, on all requests for external review for which the health carrier receives notice from the Office for Consumer Health Assistance and, upon request, submit a report to the Office for Consumer Health Assistance in a format specified by the Commissioner.  5. The report must include, aggregated for each state and for each type of health benefit plan:  (a) The total number of requests for external review;  (b) Of the total number of requests for external review, the number of requests determined to be eligible for external review; and  (c) Any other information the Office for Consumer Health Assistance may request or require.  6. A health carrier shall retain the written records required pursuant to this section for at least 3 years.  (Added to NRS by 2011, 3409)
NV Rev Stat § 695G.307 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.307 - Health carrier to provide description of external review procedures; format; contents.

  1. A health carrier shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage or other evidence of coverage it provides to covered persons.  2. The description required by subsection 1 must be in a format prescribed by the Commissioner.  3. The description required by subsection 1 must include a statement that informs the covered person of the right of the covered person to file a request for an external review of an adverse determination with the Office for Consumer Health Assistance. The statement may explain that external review is available when the adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care or effectiveness. The statement must include the telephone number and address of the Office for Consumer Health Assistance.  4. In addition to the requirements of subsection 3, the statement must inform the covered person that, when filing a request for an external review, the covered person will be required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.  (Added to NRS by 2011, 3409)
NV Rev Stat § 695G.310 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.310 - Annual report; requirements.

On or before December 31 of each year, each health carrier shall file a written report with the Office for Consumer Health Assistance setting forth the total number of:  1. Requests for an external review of an adverse decision made by the health carrier which were granted by the Office for Consumer Health Assistance during the immediately preceding year; and  2. Adverse determinations of the health carrier that were:  (a) Upheld during the immediately preceding year.  (b) Reversed during the immediately preceding year.  (Added to NRS by 2003, 783; A 2005, 1026; 2011, 3415)
NV Rev Stat § 695G.320 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.320 - Provision of health care services to recipients of Medicaid or enrollees in Children’s Health Insurance Program: Requirement to contract with psychiatric hospital for inclusion in network of providers. [Effective January 1, 2020.]

A managed care organization that provides health care services to recipients of Medicaid under the State Plan for Medicaid or insurance pursuant to the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Health and Human Services shall negotiate in good faith to enter into a contract with a psychiatric hospital with an endorsement as a crisis stabilization center pursuant to NRS 449.0915 to include the psychiatric hospital in the network of providers under contract with the managed care organization to provide services to recipients of Medicaid or insureds in the Children’s Health Insurance Program, as applicable.  (Added to NRS by 2019, 1927, effective January 1, 2020)