reglab/statecodes huggingface dataset:
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.127 - Contracts between managed care organization and provider of health care: Managed care organization required to use form to obtain information on provider of health care; modification; submission by managed care organization of schedule of payments to provider.

1. A managed care organization shall not contract with a provider of health care to provide health care to an insured unless the managed care organization uses the form prescribed by the Commissioner pursuant to NRS 629.095 to obtain any information related to the credentials of the provider of health care.
2. A contract between a managed care organization and a provider of health care may be modified:
(a) At any time pursuant to a written agreement executed by both parties.
(b) Except as otherwise provided in this paragraph, by the managed care organization upon giving to the provider 45 days’ written notice of the modification of the managed care organization’s schedule of payments, including any changes to the fee schedule applicable to the provider’s practice. If the provider fails to object in writing to the modification within the 45-day period, the modification becomes effective at the end of that period. If the provider objects in writing to the modification within the 45-day period, the modification must not become effective unless agreed to by both parties as described in paragraph (a).
3. If a managed care organization contracts with a provider of health care to provide health care services pursuant to chapter 689A, 689B, 689C, 695A, 695B or 695C of NRS, the managed care organization shall:
(a) If requested by the provider of health care at the time the contract is made, submit to the provider of health care the schedule of payments applicable to the provider of health care; or
(b) If requested by the provider of health care at any other time, submit to the provider of health care the schedule of payments, including any changes to the fee schedule applicable to the provider’s practice, specified in paragraph (a) within 7 days after receiving the request.
4. As used in this section, "provider of health care" means a provider of health care who is licensed pursuant to chapter 630, 631, 632 or 633 of NRS.
(Added to NRS by 2001, 2736; A 2003, 3371; 2011, 2536)—(Substituted in revision for NRS 695G.430)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.130 - Report regarding methods for reviewing quality of health care services: Form of report; availability for public inspection.

1. In addition to any other report which is required to be filed with the Commissioner, each managed care organization shall file with the Commissioner, with its annual filing made pursuant to NRS 686B.070 of forms and rates relating to policies of insurance for individuals and small employer groups, a report regarding its methods for reviewing the quality of health care services provided to its insureds. The report must be submitted on a form prescribed by the Commissioner.
2. A report filed pursuant to this section must be made available for public inspection within a reasonable time after it is received by the Commissioner.
3. As used in this section, "small employer" has the meaning ascribed to it in NRS 689C.095.
(Added to NRS by 1997, 305; A 1997, 3041; 2013, 3650; 2017, 2401)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.150 - Authorization of recommended and covered health care services required.

Each managed care organization shall authorize coverage of a health care service that has been recommended for the insured by a provider of health care acting within the scope of his or her practice if that service is covered by the health care plan of the insured, unless:
1. The decision not to authorize coverage is made by a physician who:
(a) Is licensed to practice medicine in the State of Nevada pursuant to chapter 630 or 633 of NRS;
(b) Possesses the education, training and expertise to evaluate the medical condition of the insured; and
(c) Has reviewed the available medical documentation, notes of the attending physician, test results and other relevant medical records of the insured.
The physician may consult with other providers of health care in determining whether to authorize coverage.
2. The decision not to authorize coverage and the reason for the decision have been transmitted in writing in a timely manner to the insured, the provider of health care who recommended the service and the primary care physician of the insured, if any.
(Added to NRS by 1997, 302; A 2003, 1181)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.155 - Managed care organization required to offer and issue plan regardless of health status of persons; prohibited acts; authority to include wellness program in plan that offers discounts based on health status under certain circumstances.

1. A managed care organization shall offer and issue a health benefit plan to any person regardless of the health status of the person or any dependent of the person. Such health status includes, without limitation:
(a) Any preexisting medical condition of the person, including, without limitation, any physical or mental illness;
(b) The claims history of the person, including, without limitation, any prior health care services received by the person;
(c) Genetic information relating to the person; and
(d) Any increased risk for illness, injury or any other medical condition of the person, including, without limitation, any medical condition caused by an act of domestic violence.
2. A managed care organization that offers or issues a health benefit plan shall not:
(a) Deny, limit or exclude a covered benefit based on the health status of an insured; or
(b) Require an insured, as a condition of enrollment or renewal, to pay a premium, deductible, copay or coinsurance based on his or her health status which is greater than the premium, deductible, copay or coinsurance charged to a similarly situated insured who does not have such a health status.
3. A managed care organization that offers or issues a health benefit plan shall not adjust a premium, deductible, copay or coinsurance for any insured on the basis of genetic information relating to the insured or the covered dependent of the insured.
4. A managed care organization that offers or issues a health benefit plan may include in the plan a wellness program that reduces a premium, deductible or copayment based on health status if:
(a) An insured who is eligible to participate in the wellness program is given the opportunity to qualify for the discount at least once each year;
(b) The amount of all discounts provided pursuant to such a wellness program does not exceed 30 percent, or if the program is designed to prevent or reduce tobacco use, 50 percent, of the cost of coverage for an insured or an insured and his or her dependents, as applicable, under the plan;
(c) The wellness program is reasonably designed to promote health or prevent disease;
(d) The managed care organization ensures that the full discount under the wellness program is available to all similarly situated insureds by providing a reasonable alternative standard by which an insured may qualify for the discount which, if based on health status, must accommodate the recommendations of the physician of the insured; and
(e) The plan discloses in all plan materials describing the terms of the wellness program, and in any disclosure that an insured did not satisfy the initial standard to be eligible for the discount, the availability of a reasonable alternative standard described in paragraph (d).
5. As used in this section, "health benefit plan" has the meaning ascribed to it in NRS 687B.470.
(Added to NRS by 2019, 313)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.160 - Written criteria concerning coverage of health care services and standards for quality of health care services.

1. Each managed care organization shall establish written criteria:
(a) Setting forth the manner in which it determines whether to authorize coverage of a health care service; and
(b) Setting forth its method for reviewing standards for the quality of health care services provided to an insured.
2. Such written criteria must be:
(a) Developed with the assistance of practicing providers of health care;
(b) Developed using generally recognized and, if appropriate, specialized clinical principles and processes;
(c) Reviewed at least one time each year and, if appropriate, updated; and
(d) Made available to an insured for review upon request of the insured any time that the managed care organization denies coverage of a specific health care service to the insured.
(Added to NRS by 1997, 302)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.163 - Plan covering prescription drugs: Provision of notice and information regarding use of formulary.

1. A managed care organization that offers or issues a health care plan which provides coverage for prescription drugs shall include with any summary, certificate or evidence of that coverage provided to an insured, notice of whether a formulary is used and, if so, of the opportunity to secure information regarding the formulary from the organization pursuant to subsection 2. The notice required by this subsection must:
(a) Be in a language that is easily understood and in a format that is easy to understand;
(b) Include an explanation of what a formulary is; and
(c) If a formulary is used, include:
(1) An explanation of:
(I) How often the contents of the formulary are reviewed; and
(II) The procedure and criteria for determining which prescription drugs are included in and excluded from the formulary; and
(2) The telephone number of the organization for making a request for information regarding the formulary pursuant to subsection 2.
2. If a managed care organization offers or issues a health care plan which provides coverage for prescription drugs and a formulary is used, the organization shall:
(a) Provide to any insured or participating provider of health care, upon request:
(1) Information regarding whether a specific drug is included in the formulary.
(2) Access to the most current list of prescription drugs in the formulary, organized by major therapeutic category, with an indication of whether any listed drugs are preferred over other listed drugs. If more than one formulary is maintained, the organization shall notify the requester that a choice of formulary lists is available.
(b) Notify each person who requests information regarding the formulary, that the inclusion of a drug in the formulary does not guarantee that a provider of health care will prescribe that drug for a particular medical condition.
(Added to NRS by 2001, 866)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.1635 - Plan covering prescription drugs: Required actions by managed care 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 managed care organization who has issued a health care plan which provides coverage for prescription drugs shall, notwithstanding any provision of the health care plan to the contrary:
(a) Waive any provision of the health care plan restricting the time within which an insured may refill a covered prescription if the insured:
(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 insured 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, 829)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.166 - Plan covering prescription drugs prohibited from limiting or excluding coverage for prescription drug previously approved for medical condition of insured; exceptions.

1. Except as otherwise provided in this section, a health care plan 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 managed care organization for a medical condition of an insured and the insured’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 insured; and
(b) Is appropriately prescribed and considered safe and effective for treating the medical condition of the insured.
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 insured 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 plan that is medically appropriate for the insured; 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 plan.
3. Any provision of a health care plan 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, 866; A 2003, 2301; 2017, 640)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.1665 - Required provision in plan covering prescription drugs concerning coverage for prescription drugs irregularly dispensed for purpose of synchronization of chronic medications; prohibited acts; exception.

1. A managed care organization that offers or issues a health care plan which provides coverage for prescription drugs:
(a) Must authorize coverage for and may apply a copayment and deductible to a prescription that is dispensed by a pharmacy for less than a 30-day supply if, for the purpose of synchronizing the insured’s chronic medications:
(1) The prescriber or pharmacist determines that filling or refilling the prescription in that manner is in the best interest of the insured; and
(2) The insured requests less than a 30-day supply.
(b) May not deny coverage for a prescription described in paragraph (a) which is otherwise approved for coverage by the managed care organization.
(c) Unless otherwise provided by a contract or other agreement, may not prorate any pharmacy dispensing fees for a prescription described in paragraph (a).
2. An evidence of coverage subject to the provisions of this chapter which provides coverage for prescription drugs and that is delivered, issued for delivery or renewed on or after January 1, 2017, has the legal effect of providing that coverage subject to the requirements of this section, and any provision of the evidence of coverage or renewal which is in conflict with this section is void.
3. The provisions of this section do not apply to unit-of-use packaging for which synchronization is not practicable or to a controlled substance.
4. As used in this section:
(a) "Chronic medication" means any drug that is prescribed to treat any disease or other condition which is determined to be permanent, persistent or lasting indefinitely.
(b) "Synchronization" means the alignment of the dispensing of multiple medications by a single contracted pharmacy for the purpose of improving a patient’s adherence to a prescribed course of medication.
(c) "Unit-of-use packaging" means medication that is prepackaged by the manufacturer in blister packs, compliance packs, course-of-therapy packs or any other packaging which is designed and intended to be dispensed directly to the patient without modification by the dispensing pharmacy, except for the addition of a prescription label.
(Added to NRS by 2015, 2129)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.167 - Plan covering treatment of cancer through use of chemotherapy: Prohibited acts related to orally administered chemotherapy.

1. A managed care organization that offers or issues a health care plan which provides coverage for the treatment of cancer through the use of chemotherapy shall not:
(a) Require a copayment, deductible or coinsurance amount for chemotherapy administered orally by means of a prescription drug in a combined amount that is more than $100 per prescription. The limitation on the amount of the deductible that may be required pursuant to this paragraph does not apply to a health benefit plan, as defined in NRS 687B.470, if the health benefit plan is a high deductible health plan, as defined in 26 U.S.C. § 223, and the amount of the annual deductible has not been satisfied.
(b) Make the coverage subject to monetary limits that are less favorable for chemotherapy administered orally by means of a prescription drug than the monetary limits applicable to chemotherapy which is administered by injection or intravenously.
(c) Decrease the monetary limits applicable to chemotherapy administered orally by means of a prescription drug or to chemotherapy which is administered by injection or intravenously to meet the requirements of this section.
2. An evidence of coverage for a health care plan subject to the provisions of this chapter which provides coverage for the treatment of cancer through the use of chemotherapy and that is delivered, issued for delivery or renewed on or after January 1, 2015, has the legal effect of providing that coverage subject to the requirements of this section, and any provision of the evidence of coverage or renewal which is in conflict with this section is void.
3. Nothing in this section shall be construed as requiring a managed care organization to provide coverage for the treatment of cancer through the use of chemotherapy administered by injection or intravenously or administered orally by means of a prescription drug.
(Added to NRS by 2013, 2001; A 2013, 3660)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.168 - Required provision in plan covering treatment of colorectal cancer concerning coverage for colorectal cancer screening.

1. A health care plan issued by a managed care organization that provides coverage for the treatment of colorectal cancer must provide coverage for colorectal cancer screening in accordance with:
(a) The guidelines concerning colorectal cancer screening which are published by the American Cancer Society; or
(b) Other guidelines or reports concerning colorectal cancer screening which are published by nationally recognized professional organizations and which include current or prevailing supporting scientific data.
2. An evidence of coverage for a health care plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2003, has the legal effect of including the coverage required by this section, and any provision of the evidence of coverage that conflicts with the provisions of this section is void.
(Added to NRS by 2003, 1337)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.170 - Required provision concerning coverage for medically necessary emergency services at any hospital; prohibited acts.

1. Each managed care organization shall provide coverage for medically necessary emergency services provided at any hospital.
2. A managed care organization shall not require prior authorization for medically necessary emergency services.
3. As used in this section, "medically necessary emergency services" means health care services that are provided to an insured by a provider of health care after the sudden onset of a medical condition that manifests itself by symptoms of such sufficient severity that a prudent person would believe that the absence of immediate medical attention could result in:
(a) Serious jeopardy to the health of an insured;
(b) Serious jeopardy to the health of an unborn child;
(c) Serious impairment of a bodily function; or
(d) Serious dysfunction of any bodily organ or part.
4. A health care plan subject to the provisions of this section that is delivered, issued for delivery or renewed on or after October 1, 1999, has the legal effect of including the coverage required by this section, and any provision of the plan or the renewal which is in conflict with this section is void.
(Added to NRS by 1997, 304; A 1999, 3097)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.1702 - Plan covering prescription drugs: Submission to step therapy protocol for drug to treat psychiatric condition prohibited in certain circumstances.

1. A health care plan which provides coverage for prescription drugs must not require an insured to submit to 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 insured, if:
(a) The drug has been approved by the Food and Drug Administration with indications for the psychiatric condition of the insured 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 insured 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 managed care organization is located 60 miles or more from the residence of the insured; and
(c) The practitioner listed in paragraph (b) who prescribed the drug knows, based on the medical history of the insured, 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 a health care plan 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 a health care plan offered by a managed care 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 managed care organization. The term does not include an arrangement for the financing of premiums.
(c) "Step therapy protocol" means a procedure that requires an insured 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 insured before his or her health care plan provides coverage for the recommended drug.
(Added to NRS by 2023, 1789)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.1707 - Required provision concerning coverage for testing, treatment and prevention of sexually transmitted diseases; required provision concerning coverage for condoms for certain insureds.

1. A managed care organization that offers or issues a health care plan shall include in the plan:
(a) Coverage of testing for, treatment of and prevention of sexually transmitted diseases, including, without limitation,
Chlamydia trachomatis
, gonorrhea, syphilis, human immunodeficiency virus and hepatitis B and C, for all insureds, regardless of age. Such coverage must include, without limitation, the coverage required by NRS 695G.1705 and 695G.1714.
(b) Unrestricted coverage of condoms for insureds who are 13 years of age or older.
2. A health care plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by subsection 1, and any provision of the plan that conflicts with the provisions of this section is void.
(Added to NRS by 2023, 3529)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.1712 - Required provision concerning coverage for screening, genetic counseling and testing related to BRCA gene in certain circumstances.

1. A managed care organization that issues a health care plan shall provide coverage for screening, genetic counseling and testing for harmful mutations in the BRCA gene for women under circumstances where such screening, genetic counseling or testing, as applicable, is required by NRS 457.301.
2. A managed care organization shall ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the managed care organization.
3. A health care plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2022, has the legal effect of including the coverage required by subsection 1, and any provision of the plan that conflicts with the provisions of this section is void.
4. As used in this section:
(a) "Network plan" means a health care plan offered by a managed care organization under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the managed care organization. The term does not include an arrangement for the financing of premiums.
(b) "Provider of health care" has the meaning ascribed to it in NRS 629.031.
(Added to NRS by 2021, 785)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.1714 - Required provision concerning coverage for examination of person who is pregnant for certain diseases.

1. A managed care organization that issues a health care plan shall provide coverage for the examination of a person who is pregnant for the discovery of:
(a)
Chlamydia trachomatis
, gonorrhea, hepatitis B and hepatitis C in accordance with NRS 442.013.
(b) Syphilis in accordance with NRS 442.010.
2. The coverage required by this section must be provided:
(a) Regardless of whether the benefits are provided to the insured by a provider of health care, facility or medical laboratory that participates in the network plan of the managed care organization; and
(b) Without prior authorization.
3. A health care plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2021, has the legal effect of including the coverage required by subsection 1, and any provision of the plan that conflicts with the provisions of this section is void.
4. As used in this section:
(a) "Medical laboratory" has the meaning ascribed to it in NRS 652.060.
(b) "Network plan" means a health care plan offered by a managed care organization under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the managed care organization. The term does not include an arrangement for the financing of premiums.
(c) "Provider of health care" has the meaning ascribed to it in NRS 629.031.
(Added to NRS by 2021, 2583)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.1716 - Health care plan covering maternity care: Prohibited acts by managed care organization if insured is acting as gestational carrier; child deemed child of intended parent for purposes of plan.

1. A managed care organization that offers or issues a health care plan that includes coverage for maternity care shall not deny, limit or seek reimbursement for maternity care because the insured is acting as a gestational carrier.
2. If an insured acts as a gestational carrier, the child shall be deemed to be a child of the intended parent, as defined in NRS 126.590, for purposes related to the health care plan.
3. As used in this section, "gestational carrier" has the meaning ascribed to it in NRS 126.580.
(Added to NRS by 2019, 1008)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.172 - Plan covering prescription drugs: Denial of coverage prohibited for early refills of otherwise covered topical ophthalmic products.

1. A managed care organization which offers or issues a health care plan that provides coverage for prescription drugs shall not deny coverage for a topical ophthalmic product which is otherwise approved for coverage by the managed care organization when the insured, pursuant to NRS 639.2395, receives a refill of the product:
(a) After 21 days or more but before 30 days after receiving any 30-day supply of the product;
(b) After 42 days or more but before 60 days after receiving any 60-day supply of the product; or
(c) After 63 days or more but before 90 days after receiving any 90-day supply of the product.
2. The provisions of this section do not affect any deductibles, copayments or coinsurance authorized or required pursuant to the health care plan.
3. An evidence of coverage subject to the provisions of this chapter which provides coverage for prescription drugs and that is delivered, issued for delivery or renewed on or after January 1, 2016, has the legal effect of including the coverage required by this section, and any provision of the evidence of coverage or renewal which is in conflict with this section is void.
4. As used in this section, "topical ophthalmic product" means a liquid prescription drug which is applied directly to the eye from a bottle or by means of a dropper.
(Added to NRS by 2015, 210)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.174 - Required provision concerning coverage for management and treatment of sickle cell disease and its variants; plan covering prescription drugs required to provide coverage for medically necessary prescription drugs to treat sickle cell disease and its variants.

1. A managed care organization that issues a health care plan shall include in the plan coverage for:
(a) Necessary case management services for an insured diagnosed with sickle cell disease and its variants; and
(b) Medically necessary care for an insured who has been diagnosed with sickle cell disease and its variants.
2. A managed care organization that issues a health care plan which provides coverage for prescription drugs shall include in the plan coverage for medically necessary prescription drugs to treat sickle cell disease and its variants.
3. A managed care organization shall establish a plan for each insured under 18 years of age who has been diagnosed with sickle cell disease and its variants to transition the insured from pediatric care to adult care when the insured reaches 18 years of age.
4. A managed care organization may use medical management techniques, including, without limitation, any available clinical evidence, to determine the frequency of or treatment relating to any benefit required by this section or the type of provider of health care to use for such treatment.
5. As used in this section:
(a) "Case management services" means medical or other health care management services to assist patients and providers of health care, including, without limitation, identifying and facilitating additional resources and treatments, providing information about treatment options and facilitating communication between providers of services to a patient.
(b) "Medical management technique" means a practice which is used to control the cost or utilization of health care services. The term includes, without limitation, the use of step therapy, prior authorization or categorizing drugs and devices based on cost, type or method of administration.
(c) "Sickle cell disease and its variants" has the meaning ascribed to it in NRS 439.4927.
(Added to NRS by 2019, 2175)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.175 - Contracts for provision of emergency medical services, outpatient services or inpatient services with hospital or other facility that provides acute care in smaller city or county: Prohibited acts.

1. If a managed care organization contracts for the provision of emergency medical services, outpatient services or inpatient services with a hospital or other licensed health care facility that provides acute care and is located in a city whose population is less than 60,000 or a county whose population is less than 100,000, the managed care organization shall not:
(a) Prohibit an insured from receiving services covered by the health care plan of the insured at that hospital or licensed health care facility if the services are provided by a provider of health care with whom the managed care organization has contracted for the provision of the services;
(b) Refuse to provide coverage for services covered by the health care plan of an insured that are provided to the insured at that hospital or licensed health care facility if the services were provided by a provider of health care with whom the managed care organization has contracted for the provision of the services;
(c) Refuse to pay a provider of health care with whom the managed care organization has contracted for the provision of services for providing services to an insured at that hospital or licensed health care facility if the services are covered by the health care plan of the insured;
(d) Discourage a provider of health care with whom the managed care organization has contracted for the provision of services from providing services to an insured at that hospital or licensed health care facility that are covered by the health care plan of the insured; or
(e) Offer or pay any type of material inducement, bonus or other financial incentive to a provider of health care:
(1) To provide services to an insured that are covered by the health care plan of the insured at another hospital or licensed health care facility; or
(2) Not to provide services to an insured at that hospital or licensed health care facility that are covered by the health care plan of the insured.
2. Nothing in this section prohibits a managed care organization from informing an insured that enhanced health care services are available at a hospital or licensed health care facility other than the hospital or licensed health care facility described in subsection 1 with which the managed care organization contracts for the provision of emergency medical services, outpatient services or inpatient services.
(Added to NRS by 1999, 1945; A 2001, 1998)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.176 - Plan covering anatomical gifts, organ transplants or treatments or services related to organ transplants: Prohibited acts by managed care organization if insured is person with disability.

1. A managed care organization that offers or issues a health care plan that includes coverage for anatomical gifts, organ transplants or treatments or services related to an organ transplant shall not:
(a) Deny, limit or seek reimbursement from an insured for care related to an organ transplant because the insured is a person with a disability;
(b) Deny a person with a disability eligibility or continued eligibility to enroll or renew coverage to avoid providing coverage in accordance with this section;
(c) Reduce or limit the reimbursement of or otherwise penalize a provider of medical or related services because the provider of medical or related services acted in accordance with NRS 460.160; or
(d) Provide monetary or nonmonetary incentives for a provider of medical or related services to induce the provider of medical or related services to provide care to an insured in a manner inconsistent with NRS 460.160.
2. As used in this section:
(a) "Anatomical gift" has the meaning ascribed to it in NRS 451.513.
(b) "Disability" has the meaning ascribed to it in 42 U.S.C. § 12102(1).
(c) "Provider of medical or related services" has the meaning ascribed to it in NRS 460.160.
(Added to NRS by 2021, 1175)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.177 - Required provision in plans covering treatment of prostate cancer concerning coverage for prostate cancer screening; prohibited acts.

1. A health care plan issued by a managed care organization that provides coverage for the treatment of prostate cancer must provide coverage for prostate cancer screening in accordance with:
(a) The guidelines concerning prostate cancer screening which are published by the American Cancer Society; or
(b) Other guidelines or reports concerning prostate cancer screening which are published by nationally recognized professional organizations and which include current or prevailing supporting scientific data.
2. A health care plan issued by a managed care organization that provides coverage for the treatment of prostate cancer must not require an insured to obtain prior authorization for any service provided pursuant to subsection 1.
3. Any evidence of coverage for a health care plan issued by a managed care organization that provides coverage for the treatment of prostate cancer which is delivered, issued for delivery or renewed on or after July 1, 2007, has the legal effect of including the coverage required by subsection 1, and any provision of the evidence of coverage or the renewal which is in conflict with subsection 1 is void.
(Added to NRS by 2007, 3242)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.180 - Quality assurance program: Requirements; written description; informing providers; necessary staff; review; responsibility for activities.

1. Each managed care organization shall establish a quality assurance program designed to direct, evaluate and monitor the effectiveness of health care services provided to its insureds. The program must include, without limitation:
(a) A method for analyzing the outcomes of health care services;
(b) Peer review;
(c) A system to collect and maintain information related to the health care services provided to insureds;
(d) Recommendations for remedial action; and
(e) Written guidelines that set forth the procedures for remedial action when problems related to quality of care are identified.
2. Each managed care organization shall:
(a) Maintain a written description of the quality assurance program established pursuant to subsection 1, including, without limitation, the specific actions used by the managed care organization to promote adequate quality of health care services provided to insureds and the persons responsible for such actions;
(b) Provide information to each provider of health care whom it employs or with whom it contracts to provide health care services to insureds regarding the manner in which the quality assurance program functions;
(c) Provide the necessary staff to implement the quality assurance program and to evaluate the effectiveness of the program; and
(d) At least one time each year, review the continuity and effectiveness of the quality assurance program, review any findings of the quality improvement committee established pursuant to NRS 695G.190 and take any reasonable actions to improve the program.
3. Each managed care organization is responsible for an activity conducted pursuant to its quality assurance program, regardless of whether the managed care organization or another entity performs the activity.
(Added to NRS by 1997, 303)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.190 - Quality improvement committee: Administration; duties.

1. As part of a quality assurance program established pursuant to NRS 695G.180, each managed care organization shall create a quality improvement committee directed by a physician who is licensed to practice medicine in the State of Nevada pursuant to chapter 630 or 633 of NRS.
2. Each managed care organization shall:
(a) Establish written guidelines setting forth the procedure for selecting the members of the committee;
(b) Select members pursuant to such guidelines; and
(c) Provide staff to assist the committee.
3. The committee shall:
(a) Select and review appropriate medical records of insureds and other data related to the quality of health care provided to insureds by providers of health care;
(b) Review the clinical processes used by providers of health care in providing services;
(c) Identify any problems related to the quality of health care provided to insureds; and
(d) Advise providers of health care regarding issues related to quality of care.
(Added to NRS by 1997, 303; A 2003, 1182)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.200 - Establishment; approval; requirements; assistance for persons filing complaints; examination.

1. Each managed care organization shall establish a system for resolving complaints of an insured concerning:
(a) Payment or reimbursement for covered health care services;
(b) Availability, delivery or quality of covered health care services, including, without limitation, an adverse determination made pursuant to utilization review; or
(c) The terms and conditions of a health care plan.
The system must be approved by the Commissioner.
2. If an insured makes an oral complaint, a managed care organization shall inform the insured that if the insured is not satisfied with the resolution of the complaint, the insured must file the complaint in writing to receive further review of the complaint.
3. Each managed care organization shall:
(a) Upon request, assign an employee of the managed care organization to assist an insured or other person in filing a complaint or appealing a decision of the review board;
(b) Authorize an insured who appeals a decision of the review board to appear before the review board to present testimony at a hearing concerning the appeal; and
(c) Authorize an insured to introduce any documentation into evidence at a hearing of a review board and require an insured to provide the documentation required by the health care plan of the insured to the review board not later than 5 business days before a hearing of the review board.
4. The Commissioner may examine the system for resolving complaints established pursuant to this section at such times as the Commissioner deems necessary or appropriate.
(Added to NRS by 1997, 305; A 2013, 3654; 2017, 2401)
2023 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)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › NRS 695G.220 - Annual report; managed care organization required to maintain records of and report 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)
2023 Nevada Revised Statutes › Chapter 695G - Managed Care › 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.

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)