reglab/statecodes huggingface dataset:
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.156 - Evidence of coverage covering prescription drugs prohibited from limiting or excluding coverage for certain prescription drugs previously approved for medical condition of enrollee; exceptions.

1. Except as otherwise provided in this section, evidence of coverage which provides coverage for prescription drugs must not limit or exclude coverage for a drug if the drug:
(a) Had previously been approved for coverage by the prepaid limited health service organization for a medical condition of an enrollee and the enrollee’s provider of health care determines, after conducting a reasonable investigation, that none of the drugs which are otherwise currently approved for coverage are medically appropriate for the enrollee; and
(b) Is appropriately prescribed and considered safe and effective for treating the medical condition of the enrollee.
2. The provisions of subsection 1 do not:
(a) Apply to coverage for any drug that is prescribed for a use that is different from the use for which that drug has been approved for marketing by the Food and Drug Administration;
(b) Prohibit:
(1) The organization from charging a deductible, copayment or coinsurance for the provision of benefits for prescription drugs to the enrollee or from establishing, by contract, limitations on the maximum coverage for prescription drugs;
(2) A provider of health care from prescribing another drug covered by the evidence of coverage that is medically appropriate for the enrollee; or
(3) The substitution of another drug pursuant to NRS 639.23286 or 639.2583 to 639.2597, inclusive; or
(c) Require any coverage for a drug after the term of the evidence of coverage.
3. Any provision of an evidence of coverage subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2001, which is in conflict with this section is void.
(Added to NRS by 2001, 865; A 2003, 2301; 2017, 640)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.158 - Evidence of coverage covering prescription drugs: Required actions by organization related to acquisition of prescription drugs for certain insureds residing in area for which emergency or disaster has been declared.

1. If the Governor or the Legislature proclaims the existence of a state of emergency or issues a declaration of disaster pursuant to NRS 414.070, a prepaid limited health service organization that has issued evidence of coverage which provides coverage for prescription drugs shall, notwithstanding any provision of the evidence of coverage to the contrary:
(a) Waive any provision of the evidence of coverage restricting the time within which an enrollee may refill a covered prescription if the enrollee:
(1) Has not exceeded the number of refills authorized by the prescribing practitioner;
(2) Resides in the area for which the emergency or disaster has been declared; and
(3) Requests the refill not later than the end of the state of emergency or disaster or 30 days after the issuance of the proclamation or declaration, whichever is later; and
(b) Authorize payment for, and may apply a copayment, coinsurance or deductible to, a supply of a covered prescription drug for up to 30 days for an enrollee who requests a refill pursuant to paragraph (a).
2. The Commissioner may extend the time periods prescribed by subsection 1 in increments of 15 or 30 days as he or she determines to be necessary.
3. As used in this section, "practitioner" has the meaning ascribed to it in NRS 639.0125.
(Added to NRS by 2021, 828)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.159 - Evidence of coverage covering prescription drugs: Use of step therapy protocol for drug to treat psychiatric condition prohibited in certain circumstances.

1. Evidence of coverage which provides coverage for prescription drugs must not require an enrollee to use a step therapy protocol before covering a drug approved by the Food and Drug Administration that is prescribed to treat a psychiatric condition of the enrollee, if:
(a) The drug has been approved by the Food and Drug Administration with indications for the psychiatric condition of the enrollee or the use of the drug to treat that psychiatric condition is otherwise supported by medical or scientific evidence;
(b) The drug is prescribed by:
(1) A psychiatrist;
(2) A physician assistant under the supervision of a psychiatrist;
(3) An advanced practice registered nurse who has the psychiatric training and experience prescribed by the State Board of Nursing pursuant to NRS 632.120; or
(4) A primary care provider that is providing care to an enrollee in consultation with a practitioner listed in subparagraph (1), (2) or (3), if the closest practitioner listed in subparagraph (1), (2) or (3) who participates in the network plan of the prepaid limited health service organization is located 60 miles or more from the residence of the enrollee; and
(c) The practitioner listed in paragraph (b) who prescribed the drug knows, based on the medical history of the enrollee, or reasonably expects each alternative drug that is required to be used earlier in the step therapy protocol to be ineffective at treating the psychiatric condition.
2. Any provision of an evidence of coverage subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, which is in conflict with this section is void.
3. As used in this section:
(a) "Medical or scientific evidence" has the meaning ascribed to it in NRS 695G.053.
(b) "Network plan" means evidence of coverage offered by a prepaid limited health service organization under which the financing and delivery of medical care is provided, in whole or in part, through a defined set of providers under contract with the prepaid limited health service organization. The term does not include an arrangement for the financing of premiums.
(c) "Step therapy protocol" means a procedure that requires an enrollee to use a prescription drug or sequence of prescription drugs other than a drug that a practitioner recommends for treatment of a psychiatric condition of the enrollee before his or her evidence of coverage provides coverage for the recommended drug.
(Added to NRS by 2023, 1788)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.170 - Procedure for modification of rates, charges, benefits, organization, operations, documents or services.

1. A prepaid limited health service organization shall file with the Commissioner a notice of any change in the rates, charges, benefits or any material change of any matter or document furnished pursuant to NRS 695F.110. The organization shall submit any proof necessary to justify the change. No such change is effective unless it is approved by the Commissioner. If the Commissioner does not disapprove of the change within 60 days after the notice is filed, the change shall be deemed approved.
2. If a prepaid limited health service organization wishes to add a limited health service, it shall submit:
(a) An application to the Commissioner;
(b) The information required by NRS 695F.110, if the information is different from the information filed with the prepaid limited health service organization’s application; and
(c) Proof of compliance with NRS 695F.200, 695F.220 and 695F.340.
A prepaid limited health service organization may not add a limited health service if the Commissioner determines that adding the service would qualify the organization as a health maintenance organization pursuant to chapter 695C of NRS or as an offeror of a health care plan for which a certificate of authority is required by any other provisions of this title.
3. If the Commissioner does not deny the application within 60 days after it is filed, the application shall be deemed approved.
4. If the application is denied, the Commissioner shall send a written notice to the prepaid limited health service organization. The notice must include the reason for the denial. The prepaid limited health service organization may request a hearing in the manner set forth in NRS 695F.140.
(Added to NRS by 1991, 1116; A 1993, 2402)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.190 - Requirements for reserve.

1. A prepaid limited health service organization shall set aside a reserve equal to 3 percent of the premiums collected from its enrollees in an amount not to exceed $500,000. The reserve is in addition to the bond or deposit filed with the Commissioner.
2. The reserve:
(a) Must be deposited in a trust account in a financial institution which is located in this state and which is federally insured or insured by a private insurer approved pursuant to NRS 672.755. The income earned on money in the account must be paid to the organization and used for its operations.
(b) Is in addition to the reserve established by the organization according to good business and accounting practices for incurred but unreported claims and other similar claims.
(Added to NRS by 1991, 1118; A 1999, 1554)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.200 - Maintenance of capital account, surety bond or deposit and risk-based capital; determination of amount of increase by Commissioner.

1. Except as otherwise provided in this section, each prepaid limited health service organization which receives a certificate of authority shall maintain all of the following:
(a) A capital account with a net worth of not less than $500,000 unless a lesser amount is permitted in writing by the Commissioner. The account must not be obligated for any accrued liabilities and must consist of cash, securities or a combination thereof which is acceptable to the Commissioner.
(b) A surety bond or deposit of cash or securities for the protection of enrollees of not less than $500,000.
(c) The amount of risk-based capital required by regulations adopted by the Commissioner pursuant to NRS 681B.550.
2. The Commissioner may increase the required amount of the organization’s capital account, surety bond or deposit and capital maintained pursuant to paragraph (c) of subsection 1 to any amount the Commissioner determines to be appropriate pursuant to subsection 3 if the Commissioner determines that such an increase is necessary to:
(a) Assist the Commissioner in the performance of his or her regulatory duties;
(b) Ensure that the organization complies with the requirements of this Code; or
(c) Ensure the solvency of the organization.
3. When determining the appropriate amount of an increase pursuant to subsection 2, the Commissioner must base his or her determination on the type, volume and nature of premiums written and premiums assumed by the organization.
4. The amount of the organization’s capital account, surety bond or deposit and capital maintained pursuant to paragraph (c) of subsection 1, as required pursuant to subsections 1 and 2:
(a) Is in addition to any reserve required by this chapter and any reserve established by the organization according to good business and accounting practices for incurred but unreported claims and other similar claims; and
(b) May increase the amount of risk-based capital required pursuant to NRS 681B.550.
5. The amount of the organization’s surety bond or deposit and capital maintained pursuant to paragraph (c) of subsection 1, as required pursuant to subsections 1 and 2 may increase the amount of net worth required pursuant to subsections 1 and 2.
(Added to NRS by 1991, 1118; A 2017, 2400; 2019, 1722)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.210 - Maintenance of fidelity bond or deposit in lieu of bond.

1. A prepaid limited health service organization shall maintain in force a fidelity bond in its own name on its officers and employees in an amount not less than $1,000,000 or in any other amount prescribed by the Commissioner.
2. Except as otherwise provided in subsection 3, the bond must be issued by an insurer licensed to do business in this State.
3. If the fidelity bond is not available from an insurer licensed to do business in this State, a prepaid limited health service organization may procure a fidelity bond from a surplus lines broker licensed pursuant to chapter 685A of NRS.
4. In lieu of the bond required pursuant to subsection 1, a prepaid limited health service organization may deposit with the Commissioner cash, securities or other investments described in paragraph (o) of subsection 1 of NRS 695F.090. The deposit must be maintained in joint custody with the Commissioner in the amount and subject to the same conditions required for a bond pursuant to this subsection.
(Added to NRS by 1991, 1119: A 2021, 2997)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.212 - Hazardous financial condition: Regulations; determination; powers of Commissioner.

1. The Commissioner may adopt regulations to define when a prepaid limited health service organization is considered to be in a hazardous financial condition and to set forth the standards to be considered by the Commissioner in determining whether the continued operation of a prepaid limited health service organization transacting business in this State may be considered to be hazardous to its enrollees or creditors or to the general public.
2. If the Commissioner determines after a hearing that any prepaid limited health service organization is in a hazardous financial condition, the Commissioner may, instead of suspending or revoking the prepaid limited health service organization’s certificate of authority, limit the certificate of authority of the prepaid limited health service organization as the Commissioner deems reasonably necessary to correct, eliminate or remedy any conduct, condition or ground that is deemed to be a cause of the hazardous financial condition.
3. An order or decision of the Commissioner under this section is subject to review in accordance with NRS 679B.310 to 679B.370, inclusive, at the request of any party to the proceedings whose interests are substantially affected.
(Added to NRS by 2017, 2399)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.220 - Contract between organization and provider or subcontractor for provision of services to enrollees: Required terms and conditions.

Each contract between a prepaid limited health service organization and a provider or other person subcontracting for the provision of a limited health service to enrollees on a prepayment basis or any other basis must contain the following terms and conditions:
1. If the prepaid limited health service organization fails to pay for a limited health service for any reason, including, but not limited to, insolvency or breach of this contract, the enrollees are not liable to the provider for any money owed to the provider pursuant to this contract.
2. A provider, agent, trustee or assignee thereof may not maintain an action at law or attempt to collect from an enrollee any money which the prepaid limited health service organization owes to the provider.
3. These provisions do not prohibit the collection of any uncovered charges which an enrollee agreed to pay or the collection of any copayment from an enrollee.
4. These provisions survive the termination of this contract, regardless of the reason for the termination.
5. The termination of this contract does not release the provider from its obligation to complete any procedure on an enrollee who is receiving treatment for a specific condition for a period not to exceed 60 days, at the same schedule of copayment or any other applicable charge in effect when this contract is terminated.
6. Any amendment to the provisions of this contract must be submitted to the Commissioner for approval before the amendment is effective.
(Added to NRS by 1991, 1118)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.230 - Establishment of system for resolution of complaints.

1. Each prepaid limited health service organization shall establish a system for the resolution of written complaints submitted by enrollees and providers.
2. The provisions of subsection 1 do not prohibit an enrollee or provider from filing a complaint with the Commissioner or limit the Commissioner’s authority to investigate such a complaint.
3. Each prepaid limited health service organization that issues any evidence of coverage that provides, delivers, arranges for, pays for or reimburses any cost of health care services through managed care shall provide a system for resolving any complaints of an enrollee or subscriber concerning those health care services that complies with the provisions of NRS 695G.200 to 695G.310, inclusive.
(Added to NRS by 1991, 1117; A 2003, 779; 2011, 3397)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.310 - Examinations and investigations.

1. The Commissioner may examine the affairs of any prepaid limited health service organization as often as is reasonably necessary to protect the interests of the residents of this State, but not less frequently than once every 3 years.
2. A prepaid limited health service organization shall make its books and records available for examination and cooperate with the Commissioner to facilitate the examination.
3. In lieu of such an examination, the Commissioner may accept the report of an examination conducted by the commissioner of insurance of another state.
4. An examination conducted pursuant to this section must be conducted in accordance with the provisions of NRS 679B.230 to 679B.300, inclusive.
5. A prepaid limited health service organization may be investigated in accordance with NRS 679B.600 to 679B.700, inclusive.
(Added to NRS by 1991, 1117; A 2007, 3331; 2019, 1722; 2021, 2997)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.320 - Annual report and financial statement; quarterly statement; additional reports; penalties for failure to file report or statement.

1. Each prepaid limited health service organization shall file with the Commissioner annually, on or before March 1, a report showing its financial condition on the last day of the preceding calendar year. The report must be verified by at least two principal officers of the organization.
2. The report must be on a form prescribed by the Commissioner and include:
(a) A financial statement of the organization, including its balance sheet and receipts and disbursements for the preceding calendar year;
(b) The number of subscribers at the beginning and the end of the year and the number of enrollments terminated during the year; and
(c) Such other information as the Commissioner may prescribe.
3. Each prepaid limited health service organization shall file with the Commissioner annually an audited financial statement prepared in accordance with the provisions of subsection 1 of NRS 680A.265.
4. Each prepaid limited health service organization shall file with the Commissioner and the National Association of Insurance Commissioners a quarterly statement in the form most recently adopted by the National Association of Insurance Commissioners for that type of insurer. The quarterly statement must be:
(a) Prepared in accordance with the instructions which are applicable to that form, including, without limitation, the required date of submission for the form; and
(b) Filed by electronic means.
5. The Commissioner may require more frequent reports containing such information as is necessary to enable the Commissioner to carry out his or her duties pursuant to this chapter.
6. The Commissioner may:
(a) Assess a fine of not more than $100 per day for each day a report or statement required pursuant to this section is not filed after the report or statement is due, but the fine must not exceed $3,000; and
(b) Suspend the organization’s certificate of authority until the organization files the report or statement, as applicable.
(Added to NRS by 1991, 1119; A 1995, 1634, 2683; 2019, 1723)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.330 - Payment of premium tax.

At the time of filing the annual report pursuant to NRS 695F.320 the prepaid limited health service organization shall forward to the Department of Taxation the tax and any penalty for nonpayment or delinquent payment of the tax in accordance with the provisions of chapter 680B of NRS.
(Added to NRS by 1991, 1121; A 1993, 1923)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.340 - Fees.

Each prepaid limited health service organization shall pay to the Commissioner the following fees:
For filing an application for a certificate of authority................................ $2,450
For issuance of a certificate of authority............................................................ 283
For the renewal of a certificate of authority................................................... 2,450
For filing a material change or addition of a limited health service.............. 100
For filing an annual report....................................................................................... 25
For filing periodic reports required by the Commissioner................................ 25
In addition to any other fee or charge, all applicable fees required pursuant to NRS 680C.110.
(Added to NRS by 1991, 1121; A 1993, 2403; 2009, 1821)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.350 - Suspension or revocation of certificate of authority: Grounds; notice; hearing; effect.

1. The Commissioner may suspend or revoke the certificate of authority of a prepaid limited health service organization issued pursuant to this chapter if the Commissioner determines that:
(a) The prepaid limited health service organization is operating substantially in violation of its basic organizational document or in a manner contrary to the manner described in and reasonably inferred from any other information submitted pursuant to NRS 695F.110 unless any amendment to its basic organization document or other information has been filed with and approved by the Commissioner;
(b) The prepaid limited health service organization issued an evidence of coverage or used rates or charges which do not comply with the requirements of NRS 695F.150 and 695F.160;
(c) The prepaid limited health service organization is not able to carry out its obligations to provide its limited health service;
(d) The prepaid limited health service organization is not financially responsible and may reasonably be expected to be unable to carry out its obligations to enrollees or prospective enrollees;
(e) The capital of the prepaid limited health service organization is less than the amount required by NRS 695F.200 or the organization has failed to correct any deficiency concerning its capital as required by the Commissioner;
(f) The prepaid limited health service organization has failed to establish and maintain in a reasonable manner the complaint system required by NRS 695F.230;
(g) The continued operation of the prepaid limited health service organization would be hazardous to its enrollees; or
(h) The prepaid limited health service organization has failed to comply with any other provision of this chapter.
2. If the Commissioner has cause to believe that grounds for the suspension or revocation of a certificate of authority of a prepaid limited health service organization exist, the Commissioner shall send written notice to the organization. The notice must include the reason for the suspension or revocation and a time not more than 30 days thereafter for a hearing on the matter. The hearing must be held in the manner set forth in NRS 695F.140.
3. If the certificate of authority of a prepaid limited health service organization is revoked, the organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs. The organization shall not:
(a) Conduct any further business unless it is essential for the orderly conclusion of its affairs; and
(b) Engage in any further advertising or solicitation.
4. The Commissioner may, by written order, permit such further operation of the organization as the Commissioner considers necessary to enable the enrollees to obtain limited health services from another organization or provider.
(Added to NRS by 1991, 1119)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.360 - Violations of chapter: Order to cease and desist; fine.

If the Commissioner, after a hearing held pursuant to NRS 695F.140, finds that a prepaid limited health service organization or other person subject to this chapter has violated a provision of this chapter, the Commissioner may:
1. Issue and cause to be served upon the organization or any other person charged with a violation of this chapter, a copy of the findings of the Commissioner and an order directing the organization or person to cease and desist from engaging in the act or practice which constitutes the violation; and
2. Impose a fine of not more than $1,000 for each violation, not to exceed a total amount of $10,000.
(Added to NRS by 1991, 1120)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.400 - License required to apply, procure, negotiate or place for another any policy or contract of organization.

A person shall not apply, procure, negotiate or place for another person any policy or contract of a prepaid limited health service organization unless he or she holds a license issued pursuant to chapter 683A of NRS.
(Added to NRS by 1991, 1118)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.410 - Confidentiality and disclosure of information.

1. Any information relating to the diagnosis, treatment or health of any enrollee obtained from the enrollee or from any provider by a prepaid limited health service organization and any contract with a provider submitted pursuant to the requirements of this chapter must not be disclosed to any person except:
(a) To the extent that it is necessary to carry out the provisions of this chapter;
(b) Upon the written consent of the enrollee or applicant, provider or prepaid limited health service organization, as appropriate;
(c) Pursuant to a specific statute or court order for the production of evidence or the discovery thereof; or
(d) For a claim or legal action if that data or information is relevant.
2. A prepaid limited health service organization may claim any privilege against disclosure which the provider who furnished the information relating to the diagnosis, treatment or health of an enrollee or applicant to the organization is entitled to claim.
(Added to NRS by 1991, 1121)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.420 - Certain insurers and organizations authorized to exclude coverage duplicated pursuant to this chapter.

Notwithstanding any other provision of this title, any person who is licensed as an insurer pursuant to chapter 680A of NRS or issued a certificate of authority pursuant to chapter 695A, 695B or 695C of NRS may exclude, in any contract or policy issued to a group, any coverage which would duplicate the coverage of a limited health service, whether for services, supplies or reimbursement, to the extent that the coverage or service is provided in accordance with this chapter pursuant to a contract or policy issued to the same group or to a part of that group by a prepaid limited health service organization or a person who is licensed as an insurer pursuant to chapter 680A of NRS or issued a certificate of authority pursuant to chapter 695A, 695B or 695C of NRS.
(Added to NRS by 1991, 1117)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.430 - Provision of services excluded from practice of any healing arts; solicitation excluded from provisions regarding solicitation or advertising by practitioner of healing art.

1. The provision of limited health services by a prepaid limited health service organization or any other person pursuant to this chapter shall not be deemed to be the practice of medicine or any other healing arts.
2. The solicitation by a prepaid limited health service organization to arrange for or provide a limited health service in accordance with this chapter does not violate any statutory provision relating to solicitation or advertising by a practitioner of a healing art.
(Added to NRS by 1991, 1117)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.440 - Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency.

1. An organization shall not, when considering eligibility for coverage or making payments under any evidence of coverage, consider the availability of, or eligibility of a person for, medical assistance under Medicaid.
2. To the extent that payment has been made by Medicaid for health care, a prepaid limited health service organization:
(a) Shall treat Medicaid as having a valid and enforceable assignment of benefits due a subscriber or claimant under the subscriber regardless of any exclusion of Medicaid or the absence of a written assignment; and
(b) May, as otherwise allowed by its evidence of coverage or contract and applicable law or regulation concerning subrogation, seek to enforce any rights of a recipient of Medicaid against any other liable party if:
(1) It is so authorized pursuant to a contract with Medicaid for managed care; or
(2) It has reimbursed Medicaid in full for the health care provided by Medicaid to its subscriber.
3. If a state agency is assigned any rights of a person who is:
(a) Eligible for medical assistance under Medicaid; and
(b) Covered by any evidence of coverage,
the prepaid limited health service organization that issued the evidence of coverage shall not impose any requirements upon the state agency except requirements it imposes upon the agents or assignees of other persons covered by any evidence of coverage.
4. If a state agency is assigned any rights of a subscriber who is eligible for medical assistance under Medicaid, a prepaid limited health service organization shall:
(a) Upon request of the state agency, provide to the state agency information regarding the subscriber to determine:
(1) Any period during which the subscriber, the spouse or a dependent of the subscriber may be or may have been covered by the organization; and
(2) The nature of the coverage that is or was provided by the organization, including, without limitation, the name and address of the subscriber and the identifying number of the evidence of coverage;
(b) Respond to any inquiry by the state agency regarding a claim for payment for the provision of any medical item or service not later than 3 years after the date of the provision of the medical item or service; and
(c) Agree not to deny a claim submitted by the state agency solely on the basis of the date of submission of the claim, the type or format of the claim form or failure to present proper documentation at the point of sale that is the basis for the claim if:
(1) The claim is submitted by the state agency not later than 3 years after the date of the provision of the medical item or service; and
(2) Any action by the state agency to enforce its rights with respect to such claim is commenced not later than 6 years after the submission of the claim.
(Added to NRS by 1995, 2437; A 2007, 2407)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.450 - Organization prohibited from asserting certain grounds to deny enrollment of child pursuant to order if parent is insured.

A prepaid limited health service organization shall not deny the enrollment of a child pursuant to an order for medical coverage under any evidence of coverage pursuant to which a parent of the child is insured on the ground that the child:
1. Was born out of wedlock;
2. Has not been claimed as a dependent on the parent’s federal income tax return; or
3. Does not reside with the parent or within the organization’s geographic area of service.
(Added to NRS by 1995, 2438)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.460 - Certain accommodations required to be made when child is covered under evidence of coverage of noncustodial parent.

If a child has coverage under any evidence of coverage pursuant to which a noncustodial parent of the child is insured, the prepaid limited health service organization issuing that evidence of coverage shall:
1. Provide to the custodial parent such information as necessary for the child to obtain any benefits under that coverage.
2. Allow the custodial parent or, with the approval of the custodial parent, a provider to submit claims for covered services without the approval of the noncustodial parent.
3. Make payments on claims submitted pursuant to subsection 2 directly to the custodial parent, the provider or an agency of this or another state responsible for the administration of Medicaid.
(Added to NRS by 1995, 2438)
2023 Nevada Revised Statutes › Chapter 695F - Prepaid Limited Health Service Organizations › NRS 695F.470 - Organization required to authorize enrollment of child of parent who is required by order to provide medical coverage under certain circumstances; termination of coverage of child.

If a parent is required by an order for medical coverage to provide coverage for a child and the parent is eligible for coverage of members of the family of the parent under any evidence of coverage, the prepaid limited health service organization that issued the evidence of coverage:
1. Shall, if the child is otherwise eligible for that coverage, allow the parent to enroll the child in that coverage without regard to any restrictions upon periods for enrollment.
2. Shall, if:
(a) The child is otherwise eligible for that coverage; and
(b) The parent is enrolled in that coverage but fails to apply for enrollment of the child,
enroll the child in that coverage upon application by the other parent of the child, or by an agency of this or another state responsible for the administration of Medicaid or a state program for the enforcement of child support established pursuant to 42 U.S.C. §§ 651 et seq., without regard to any restrictions upon periods for enrollment.
3. Shall not terminate the enrollment of the child in that coverage or otherwise eliminate that coverage of the child unless the prepaid limited health service organization has written proof that:
(a) The order for medical coverage is no longer in effect; or
(b) The child is or will be enrolled in comparable coverage through another insurer on or before the effective date of the termination of enrollment or elimination of coverage.
(Added to NRS by 1995, 2438)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.010 - Definitions.

As used in this chapter, unless the context otherwise requires, the words and terms defined in NRS 695G.012 to 695G.085, inclusive, have the meanings ascribed to them in those sections.
(Added to NRS by 1997, 301; A 2003, 783; 2011, 3410)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.012 - "Adverse determination" defined.

"Adverse determination" means a determination by a health carrier or utilization review organization that an admission, availability of care, continued stay or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and the requested service or payment for the service is therefore denied, reduced or terminated.
(Added to NRS by 2003, 779; A 2011, 3410)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.014 - "Authorized representative" defined.

"Authorized representative" means:
1. A person to whom a covered person has given express written consent to represent the covered person in an external review of an adverse determination conducted pursuant to NRS 695G.241 to 695G.310, inclusive;
2. A person authorized by law to provide substituted consent for a covered person; or
3. A family member of a covered person or the covered person’s treating provider only when the covered person is unable to provide consent.
(Added to NRS by 2003, 779; A 2011, 3410)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.016 - "Clinical peer" defined.

"Clinical peer" means a physician who is:
1. Engaged in the practice of medicine; and
2. Certified or is eligible for certification by a member board of the American Board of Medical Specialties in the same or similar area of practice as is the health care service that is the subject of a final adverse determination.
(Added to NRS by 2003, 779)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.024 - "Health carrier" defined.

"Health carrier" means an entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the Commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services, including, without limitation, a sickness and accident health insurance company, a health maintenance organization, a nonprofit hospital and health service corporation or any other entity providing a plan of health insurance, health benefits or health care services.
(Added to NRS by 2011, 3398)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.026 - "Independent review organization" defined.

"Independent review organization" means an entity that:
1. Conducts an independent external review of an adverse determination; and
2. Is certified by the Commissioner in accordance with NRS 683A.3715 and 683A.372.
(Added to NRS by 2003, 779; A 2011, 3410)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.040 - "Managed care" defined.

"Managed care" means a system for delivering health care services that encourages the efficient use of health care services by using employed or independently contracted providers of health care and by using various techniques which may include, without limitation:
1. Managing the health care services of an insured who has a serious, complicated, protracted or other health-related condition that requires the use of numerous providers of health care or other costly services;
2. Providing utilization review;
3. Offering financial incentives for the effective use of health care services; or
4. Any combination of those techniques.
(Added to NRS by 1997, 301)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.053 - "Medical or scientific evidence" defined.

"Medical or scientific evidence" means evidence found in the following sources:
1. Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;
2. Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Library of Medicine of the National Institutes of Health for indexing in
Index Medicus
(MEDLINE) and Elsevier for indexing in
Excerpta Medica
(EMBASE);
3. Medical journals recognized by the Secretary of Health and Human Services pursuant to section 1861(t)(2) of the Social Security Act, 42 U.S.C. § 1395x;
4. The following standard reference compendia:
(a)
AHFS Drug Information
published by the American Society of Health-System Pharmacists;
(b) Drug Facts and Comparisons published by Wolter Kluwers Health;
(c)
Accepted Dental Therapeutics
published by the American Dental Association; and
(d) The United States Pharmacopoeia’s Drug Quality and Information Program;
5. Findings, studies or research conducted by or under the auspices of the Federal Government and nationally recognized federal research institutes, including, without limitation:
(a) The Agency for Healthcare Research and Quality;
(b) The National Institutes of Health;
(c) The National Cancer Institute;
(d) The National Academy of Sciences of the National Academies;
(e) The Centers for Medicare and Medicaid Services;
(f) The Food and Drug Administration; and
(g) Any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health care services; or
6. Any other source of medical or scientific evidence that is comparable to the sources listed in subsections 1 to 5, inclusive.
(Added to NRS by 2011, 3398)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.055 - "Medically necessary" defined.

"Medically necessary" means health care services or products that a prudent physician would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and:
1. Provided in accordance with generally accepted standards of medical practice;
2. Clinically appropriate with regard to type, frequency, extent, location and duration;
3. Not primarily provided for the convenience of the patient, physician or other provider of health care;
4. Required to improve a specific health condition of an insured or to preserve the existing state of health of the insured; and
5. The most clinically appropriate level of health care that may be safely provided to the insured.
(Added to NRS by 2003, 779)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.060 - "Primary care physician" defined.

"Primary care physician" means a physician or group of physicians who:
1. Provides initial and primary health care services to an insured;
2. Maintains the continuity of care for the insured; and
3. May refer the insured to a specialized provider of health care.
(Added to NRS by 1997, 302)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.070 - "Provider of health care" defined.

"Provider of health care" means:
1. A physician or other health care practitioner who is licensed or otherwise authorized in this State to furnish any health care service; and
2. An institution providing health care services or other setting in which health care services are provided, including, without limitation, a hospital, surgical center for ambulatory patients, facility for skilled nursing, residential facility for groups, laboratory and any other such licensed facility.
(Added to NRS by 1997, 302; A 2011, 3411)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.080 - "Utilization review" defined.

1. "Utilization review" means the various methods that may be used to review the amount and appropriateness of the provision of a specific health care service.
2. The term does not include an external review of an adverse determination conducted pursuant to NRS 695G.241 to 695G.310, inclusive.
(Added to NRS by 1997, 302; A 2003, 783; 2011, 3411)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.090 - Applicability of chapter and other provisions.

1. Except as otherwise provided in subsection 3, the provisions of this chapter apply to each organization and insurer that operates as a managed care organization and may include, without limitation, an insurer that issues a policy of health insurance, an insurer that issues a policy of individual or 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 shall comply with:
(a) The provisions of chapter 686A of NRS, including all obligations and remedies set forth therein; and
(b) Any other applicable provision of this title.
3. The provisions of NRS 695G.127, 695G.1639, 695G.164, 695G.1645, 695G.167 and 695G.200 to 695G.230, inclusive, do not apply to 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.
4. The provisions of NRS 695C.1735 and 695G.1639 do not apply to a managed care organization that provides health care services to members of the Public Employees’ Benefits Program.
5. Subsections 3 and 4 do not exempt a managed care organization from any provision of this chapter for services provided pursuant to any other contract.
(Added to NRS by 1997, 302; A 2003, 783, 3371; 2009, 1477; 2013, 2001; 2023, 820, 1353)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.095 - Offering policy of health insurance for purposes of establishing health savings account.

A managed care organization may, subject to regulation by the Commissioner, offer a policy of health insurance that has a high deductible and is in compliance with 26 U.S.C. § 223 for the purposes of establishing a health savings account.
(Added to NRS by 2005, 2159)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.110 - Medical director required to be physician licensed in this State.

Each managed care organization shall employ or contract with a physician who is licensed to practice medicine in the State of Nevada pursuant to chapter 630 or 633 of NRS to serve as its medical director.
(Added to NRS by 1997, 305; A 2003, 1181)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.120 - Utilization review: Development and maintenance of written policies and procedures for use by managed care organization and subcontractors.

Each managed care organization shall:
1. Develop and maintain written policies and procedures setting forth the manner in which it conducts utilization review; and
2. Require any person with whom it subcontracts to provide utilization review to use the same policies and procedures developed pursuant to subsection 1.
(Added to NRS by 1997, 303)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.125 - Contracts with certain federally qualified health centers.

1. A managed care organization that delivers health care services by using independently contracted providers of health care shall use its best efforts to contract with at least one health center in each geographic area served by the organization to provide such services to insureds if the health center:
(a) Meets all conditions imposed by the organization on similarly situated providers of health care that are under contract with the organization, including, without limitation:
(1) Certification for participation in the Medicaid or Medicare program; and
(2) Requirements relating to the appropriate credentials for providers of health care; and
(b) Agrees to reasonable reimbursement rates that are generally consistent with those offered by the organization to similarly situated providers of health care that are under contract with the organization.
2. As used in this section, "health center" has the meaning ascribed to it in 42 U.S.C. § 254b.
(Added to NRS by 2001, 1925)