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- 83rd Session (2025)
Assembly Bill No. 202–Assemblymember Brown-May
CHAPTER..........
AN ACT relating to insurance; revising certain definitions for the
purposes of certain coverage for health care services; revising
provisions governing the circumstances under which a
managed care organization is not required to authorize
coverage of a health care service; revising the applicability of
certain provisions requiring certain insurers to establish a
system of procedures for resolving complaints of insured
persons and providing for the external review of an adverse
determination to include certain insurers that issue policies or
certificates that provide only dental coverage; revising the
information which a health carrier is required to provide in a
notice of an adverse determination; authorizing a dentist of a
covered person to submit to the Office for Consumer Health
Assistance in the Department of Health and Human Services
a request for an external rev iew of an adverse determination;
requiring an independent review organization to notify the
dentist of a covered person and a health carrier of certain
information and the determination and reasons of the
independent review organization; requiring a decisi on of an
independent review organization to be based, in part, on
certain documentary evidence, including any
recommendation of the dentist of the insured; and providing
other matters properly relating thereto.
Legislative Counsel’s Digest:
Existing law requires each managed care organization to authorize coverage of
a health care service that has been recommended for an 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 the decision not to authorize coverage
is made by a physician who satisfies certain conditions. (NRS 695G.150) Section 2
of this bill provides that a managed care organization is also not required to
authorize coverage if the decision n ot to authorize coverage is made by a dentist
who satisfies certain conditions.
Existing law: (1) requires a managed care organization to establish a system of
procedures for resolving complaints of a person who is insured by a managed care
organization; and (2) provides for the external review of an adverse determination
by a managed care organization. (NRS 695G.200 -695G.310) The requirement for
the establishment of a system of procedures for resolving complaints and the
provisions setting forth procedure s for the external review of an adverse
determination also apply to insurers that issue certain policies, plans, contracts and
coverage for health insurance in this State that provide, deliver, arrange for, pay for
or reimburse costs of health care through managed care, including: (1) certain
health insurance provided through a plan of self -insurance for officers and
employees of this State; (2) individual health insurance; (3) group health insurance;
(4) health benefit plans of small employers; (5) contrac ts for hospital or medical
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services; (6) health care plans issued by health maintenance organizations; and (7)
evidence of coverage issued by prepaid limited health service organizations. (NRS
287.04335, 689A.745, 689B.0285, 689C.156, 695B.380, 695C.260, 6 95F.230)
Existing law exempts a policy or certificate that provides only dental coverage from
these provisions. (NRS 695G.243) Section 3 of this bill provides that the
requirement for the establishment of a system of procedures for resolving
complaints and the provisions setting forth procedures for the external review of an
adverse determination apply to a policy or certificate that provides only dental
coverage.
Existing law requires a health carrier to notify certain persons, including a
covered person and his or her treating physician, of: (1) an adverse determination
relating to a request for the provision of or payment for a health care service or
course of treatment; and (2) certain information which must be included in such a
notice, including the a bility to file a request for an expedited external review if,
among other conditions, the insured’s treating physician makes certain written
certifications relating to the recommended or requested health care service or
treatment. (NRS 695G.245) Section 4 of this bill provides that a dentist may make
the required written certifications.
Existing law authorizes a covered person, a physician of a covered person or an
authorized representative to submit a request to the Office for Consumer Health
Assistance in the Department of Health and Human Services for an external review
of an adverse determination. (NRS 695G.251) Section 5 of this bill authorizes a
dentist of a covered person to submit such a request.
Existing law requires an independent review organiza tion that receives a
request for an external review to: (1) notify the covered person, the physician of the
covered person and the health carrier if any additional information is required to
conduct the review; (2) forward to the health carrier any informa tion received from
a covered person or the physician of a covered person; and (3) notify the covered
person, the physician of the covered person, the authorized representative of the
covered person and the health carrier of its determination and reasons th erefor.
(NRS 695G.261) Section 6 of this bill requires the independent review organization
to also: (1) notify the dentist of the covered person if any additional information is
required to conduct the review; (2) forward to the health carrier any informat ion
received from the dentist of a covered person; and (3) notify the dentist of the
covered person of its determination and reasons therefor.
Existing law requires an independent review organization to notify a covered
person, the physician of the covere d person, the authorized representative, if any,
and the health carrier by telephone and in writing after completing its external
review. (NRS 695G.271) Section 7 of this bill requires an independent review
organization to notify the dentist of a covered person, if applicable.
Existing law sets forth the process by which an external review of an adverse
determination must be conducted. (NRS 695G.275) Section 8 of this bill revises
provisions setting forth that process to provide a covered person’s treating dentist
with the same powers and duties with respect to that process as a covered person’s
treating physician.
Existing law requires the decision of an independent review organization
concerning a request for an external review to be based, in part, on documentary
evidence, including any recommendation of the physician of the insured. (NRS
695G.280) Section 9 of this bill requires that documentary evidence to include any
recommendation of the dentist of the insured.
Existing law provides a clinical peer who conducts or participates in an external
review of an adverse determination immunity from liability for certai n damages
relating to the external review under certain circumstances. (NRS 695G.290)
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Section 1 of this bill revises the definition of “clinical peer” to include certain
dentists.
EXPLANATION – Matter in bolded italics is new; matter between brackets [omitted material] is material to be omitted.
THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN
SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS:
Section 1. NRS 695G.016 is hereby amended to read as
follows:
695G.016 “Clinical peer” means [a] :
1. A physician who is:
[1.] (a) Engaged in the practice of medicine; and
[2.] (b) 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 [.] ; or
2. A dentist who is:
(a) Licensed by the Board of Dental Examiners of Nevada
pursuant to chapter 631 of NRS; and
(b) Engaged in the practice of dentistry.
Sec. 2. NRS 695G.150 is hereby amended to read as follows:
695G.150 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 ma de by a
physician or dentist who:
(a) Is licensed to practice medicine or dentistry in the State of
Nevada pursuant to chapter 630 , 631 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 [,] or dentist, test results and other relevant
medical records of the insured.
The physician or dentist 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 or dentist of the insured, if any.
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Sec. 3. NRS 695G.243 is hereby amended to read as follows:
695G.243 1. Except as otherwise provided in subsection 2,
the provisions of NRS 695G.200 to 695G.310, inclusive, apply to all
health carriers.
2. The provisions of subsection 1 do not apply to:
(a) A policy or certificate that provides only coverage for:
(1) A specified disease or accident;
(2) Accidents;
(3) Credit;
(4) [Dental;
(5)] Disability income;
[(6)] (5) Hospital indemnity;
[(7)] (6) Long-term care insurance;
[(8)] (7) Vision care; or
[(9)] (8) Any other limited supplemental benefit;
(b) A Medicare supplement policy of insurance, as defined in
regulations adopted by the Commissioner;
(c) Coverage under a plan through Medicare, Medicaid or the
Federal Employees Health Benefits Program, FEHBP, 5 U.S.C. §§
8901 et seq.;
(d) Any coverage issued under the Civilian Health and Medical
Program of the Uniformed Services, CHAMPUS, 10 U.S.C. §§
1071 et seq., and any coverage issued as supplemental to that
coverage;
(e) Any coverage issued as supplemental to liability insurance;
(f) Workers’ compensation or similar insurance;
(g) Automobile medical payment insurance; or
(h) Any insurance under which benefits are payable with or
without regard to fault, whether writte n on a group, blanket or
individual basis.
Sec. 4. NRS 695G.245 is hereby amended to read as follows:
695G.245 1. A health carrier shall notify the covered person
in writing of the covered person’s right to request an external review
to be conducted pursuant to NRS 695G.241 to 695G.310, inclusive,
and include the appropriate statements and information set forth in
subsection 2 at the same time the health carrier sends written notice
of an adverse determination upon completion of the health carrier’s
utilization review process set forth in NRS 683A.375 to 683A.379,
inclusive, and the regulations adopted pursuant thereto.
2. As part of the written notice required pursuant to subsection
1, a health carrier shall include the following, or substantially
equivalent, language:
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We have denied your request for the provision of or payment
for a health care service or course of treatment. You may
have the right to have our decision reviewed by health care
professionals who have no association with us if our dec ision
involved making a judgment as to the medical necessity,
appropriateness, health care setting, level of care or
effectiveness of the health care service or treatment you
requested by submitting a request for external review to the
Office for Consumer Health Assistance.
3. The Commissioner may prescribe by regulation the form and
content of the notice required pursuant to this section.
4. The health carrier shall include in the notice required
pursuant to subsection 1 a statement informing the covered person
that:
(a) If the covered person has a medical condition where the time
frame for completion of an expedited review of a grievance
involving an adverse determination set forth in NRS 695G.200 to
695G.230, inclusive, would seriously jeopardize the life or health of
the covered person or would jeopardize the covered person’s ability
to regain maximum function, the covered person or the covered
person’s authorized representative may, at the same time the
covered person or the covered person’s au thorized representative
files a request for an expedited review of a grievance involving an
adverse determination as set forth in NRS 695G.210, file a request
for an expedited external review to be conducted pursuant to NRS
695G.271 and 695G.275 if the adv erse determination involves a
denial of coverage based on a determination that the recommended
or requested health care service or treatment is experimental or
investigational and the covered person’s treating physician or
dentist, as applicable, certifies in writing that the recommended or
requested health care service or treatment that is the subject of the
adverse determination would be significantly less effective if not
promptly initiated, and the independent review organization
assigned to conduct the expedited external review will determine
whether the covered person will be required to complete the
expedited review of the grievance before conducting the expedited
external review; and
(b) The covered person or the covered person’s authorized
representative may file a grievance under the health carrier’s
internal grievance process as set forth in NRS 695G.200 to
695G.230, inclusive, but if the health carrier has not issued a written
decision to the covered person or the covered person’s authorized
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representative within 30 days after the date on which the covered
person or the covered person’s authorized representative filed the
grievance with the health carrier and the covered person or the
covered person’s authorized representative has not requested or
agreed to a delay, the covered person or the covered person’s
authorized representative may file a request for external review
pursuant to NRS 695G.251 and shall be considered to have
exhausted the health carrier’s internal grievance process.
5. In addi tion to the information required to be provided
pursuant to subsection 1, the health carrier shall include a copy of
the description of both the standard and expedited external review
procedures the health carrier is required to provide pursuant to NRS
695G.307, highlighting the provisions in the external review
procedures that give the covered person or the covered person’s
authorized representative the opportunity to submit additional
information and including any forms used to process an external
review.
6. As part of any forms provided pursuant to subsection 3, the
health carrier shall include an authorization form, or other document
approved by the Commissioner that complies with the requirements
of 45 C.F.R. § 164.508, by which the covered person, fo r purposes
of conducting an external review, authorizes the health carrier and
the covered person’s treating health care provider to disclose
protected health information, including medical records, concerning
the covered person that are pertinent to the external review.
7. As used in this section, “protected health information” has
the meaning ascribed to it in 45 C.F.R. § 160.103.
Sec. 5. NRS 695G.251 is hereby amended to read as follows:
695G.251 1. If a covered person or a physician or dentist of a
covered person receives notice of an adverse determination from a
health carrier concerning the covered person, the covered person,
the physician or dentist, as applicable, of the covered person or an
authorized representative may, within 4 months aft er receiving
notice of the adverse determination, submit a request to the Office
for Consumer Health Assistance for an external review of the
adverse determination.
2. Within 5 days after receiving a request pursuant to
subsection 1, the Office for Consumer Health Assistance shall notify
the covered person, the authorized representative or physician or
dentist, as applicable, of the covered person, the agent who
performed utilization review for the health carrier, if any, and the
health carrier that the r equest has been filed with the Office for
Consumer Health Assistance.
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3. As soon as practicable after receiving a request pursuant to
subsection 1, the Office for Consumer Health Assistance shall
assign an independent review organization from the list ma intained
pursuant to NRS 683A.3715. Each assignment made pursuant to this
subsection must be completed on a rotating basis.
4. Within 5 days after receiving notification from the Office for
Consumer Health Assistance specifying the independent review
organization assigned pursuant to subsection 3, the health carrier
shall provide to the independent review organization all documents
and materials relating to the adverse determination, including,
without limitation:
(a) Any medical records of the insured r elating to the external
review;
(b) A copy of the provisions of the health benefit plan upon
which the adverse determination was based;
(c) Any documents used by the health carrier to make the
adverse determination;
(d) The reasons for the adverse determination; and
(e) Insofar as practicable, a list that specifies each provider of
health care who has provided health care to the covered person and
the medical records of the provider of health care relating to the
external review.
Sec. 6. NRS 695G.261 is hereby amended to read as follows:
695G.261 1. Except as otherwise provided in NRS 695G.271
and 695G.275, upon receipt of a request for an external review
pursuant to NRS 695G.251, the independent review organization
shall, within 5 days after receiving the request:
(a) Review the request and the documents and materials
submitted pursuant to NRS 695G.251; and
(b) Notify the covered person, the physician or dentist, as
applicable, of the covered person and the health carrier if any
additional information is required to conduct a review of the adverse
determination. Such additional information must be provided within
5 days after receiving notice that the information is required to
conduct a review of the adverse determination. The independent
review organization shall forward to the health carrier, within 1
business day after receipt, any information received from a covered
person or the physician or dentist of a covered person.
2. Except as otherwise provided in NRS 695G.271 and
695G.275, the independent review organization shall approve,
modify or reverse the adverse determination within 15 days after it
receives the information required to make that determination
pursuant to this section. The independent review organization shall
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submit a copy of its determination, including the reasons therefor,
to:
(a) The covered person;
(b) The physician or dentist, as applicable, of the covered
person;
(c) The authorized representative of the covered person, if any;
and
(d) The health carrier.
Sec. 7. NRS 695G.271 is hereby amended to read as follows:
695G.271 1. The Office for Consumer Health Assistance
shall approve or deny a request for an external review of an adverse
determination in an expedited manner not later than 72 hours after it
receives proof from the provider of health care of the covered
person that:
(a) The adverse determination concerns an admission,
availability of care, continued stay or health care service for which
the covered person received emergency services but has not been
discharged from the facility providing the services or care; or
(b) Failure to proceed in an expedited manner may jeopardize
the life or health of the covered person or the ability of t he covered
person to regain maximum function.
2. If the Office for Consumer Health Assistance approves a
request for an external review pursuant to subsection 1, the Office
for Consumer Health Assistance shall assign the request to an
independent review organization not later than 1 working day after
approving the request. Each assignment made by the Office for
Consumer Health Assistance pursuant to this section must be
completed on a rotating basis.
3. Within 24 hours after receiving notice of the Office for
Consumer Health Assistance assigning the request, the health carrier
shall provide to the independent review organization all documents
and materials specified in subsection 4 of NRS 695G.251.
4. An independent review organization that is assi gned to
conduct an external review pursuant to subsection 2 shall, if it
accepts the assignment:
(a) Complete its external review not later than 48 hours after
receiving the assignment, unless the covered person and the health
carrier agree to a longer period;
(b) Not later than 24 hours after completing its external review,
notify the covered person, the physician or dentist, as applicable, of
the covered person, the authorized representative, if any, and the
health carrier by telephone of its determination; and
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(c) Not later than 48 hours after completing its external review,
submit a written decision of its external review to the covered
person, the physician or dentist, as applicable, of the covered
person, the authorized representative, if any, and the health carrier.
Sec. 8. NRS 695G.275 is hereby amended to read as follows:
695G.275 1. Within 4 months after receipt of a notice of an
adverse determination pursuant to NRS 695G.245 that involves a
denial of coverage based on a determination that t he health care
service or treatment recommended or requested is experimental or
investigational, a covered person or the covered person’s authorized
representative may file a request for external review with the Office
for Consumer Health Assistance pursuant to this section.
2. A covered person or the covered person’s authorized
representative may make an oral request for an expedited external
review of the adverse determination pursuant to NRS 695G.245 that
involves a denial of coverage based on a determ ination that the
health care service or treatment recommended or requested is
experimental or investigational if the covered person’s treating
physician or dentist, as applicable, certifies, in writing, that the
recommended or requested health care service or treatment that is
the subject of the request would be significantly less effective if not
promptly initiated.
3. Upon receipt of a request for an expedited external review
pursuant to subsection 2, the Office for Consumer Health Assistance
shall immediately notify the health carrier.
4. Immediately upon notice of a request for an expedited
external review pursuant to subsection 2, the health carrier shall
determine whether the request meets the requirements for review set
forth in subsection 12. The health carrier shall immediately notify
the Office for Consumer Health Assistance and the covered person
and, if applicable, the covered person’s authorized representative, of
its determination regarding eligibility.
5. The Commissioner may specify the form for the notice of
initial determination pursuant to subsection 4 and any supporting
information to be included in the notice.
6. The notice of initial determination required by subsection 4
must include a statement that a health carrier’s initial de termination
that a request which is ineligible for external review may be
appealed to the Office for Consumer Health Assistance.
7. The Office for Consumer Health Assistance may determine
that a request for an expedited external review is eligible for
external review pursuant to subsection 12 and require that it be
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referred for expedited external review notwithstanding a health
carrier’s initial determination that the request is ineligible.
8. In making a determination pursuant to subsection 7, the
decision of the Office for Consumer Health Assistance must be
made in accordance with the terms of the covered person’s health
benefit plan and is subject to all applicable provisions of the external
review process.
9. Upon receipt of the notice that the req uest for expedited
external review meets the requirements for review, the Office for
Consumer Health Assistance shall immediately assign an
independent review organization to conduct the expedited external
review from the list of approved independent revie w organizations
compiled and maintained by the Commissioner pursuant to NRS
683A.3715 and notify the health carrier of the name of the assigned
independent review organization.
10. Upon receipt of the notice pursuant to subsection 9, the
health carrier o r utilization review organization shall provide or
transmit any documents and information considered in making the
adverse determination to the assigned independent review
organization electronically or by telephone or facsimile, or any other
available expeditious method.
11. Except as otherwise provided in subsection 3, within 1
business day after receipt of a request for external review pursuant
to subsection 1, the Office for Consumer Health Assistance shall
notify the health carrier.
12. Within 5 bu siness days after receipt of the notice sent
pursuant to subsection 11, the health carrier shall conduct and
complete a preliminary review of the request to determine whether:
(a) The person is or was a covered person in the health benefit
plan at the tim e the health care service or treatment was
recommended or requested or, in the case of a retrospective review,
was a covered person in the health benefit plan at the time the health
care service or treatment was provided;
(b) The recommended or requested health care service or
treatment that is the subject of the adverse determination:
(1) Would be a covered benefit under the covered person’s
health benefit plan but for the health carrier’s determination that the
health care service or treatment is exper imental or investigational
for a particular medical condition; and
(2) Is not explicitly listed as an excluded benefit under the
covered person’s health benefit plan;
(c) The covered person’s treating physician or dentist has
certified that one of the following situations is applicable:
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(1) Standard health care services or treatments have not been
effective in improving the condition of the covered person;
(2) Standard health care services or treatments are not
medically appropriate for the covered person; or
(3) There is no available standard health care service or
treatment covered by the health carrier that is more beneficial than
the recommended or requested health care service or treatment
described in paragraph (d);
(d) The covered person’s treating physician [:] or dentist:
(1) Has recommended a health care service or treatment that
the physician or dentist certifies, in writing, is likely to be more
beneficial to the covered person, in the [physician’s] opinion [,] of
the physician or dentist, than any available standard health care
services or treatments; or
(2) Who is a licensed, board certified or board eligible
physician or dentist qualified to practice in the area of medicine or
dentistry appropriate to treat the covered person’s condition, has
certified in writing that scientifically valid studies using accepted
protocols demonstrate that the health care service or treatment
requested by the covered person that is the subject of the adverse
determination is li kely to be more beneficial to the covered person
than any available standard health care services or treatments;
(e) The covered person has exhausted the health carrier’s
internal grievance process as set forth in NRS 695G.200 to
695G.230, inclusive, unle ss the covered person is not required to
exhaust the health carrier’s internal grievance process; and
(f) The covered person has provided all the information and
forms required by the Office for Consumer Health Assistance to
process an external review, in cluding the release form provided
pursuant to subsection 6 of NRS 695G.245.
13. Within 1 business day after completion of the preliminary
review, the health carrier shall notify the Office for Consumer
Health Assistance and the covered person, and, if ap plicable, the
covered person’s authorized representative, in writing, whether the
request is:
(a) Complete;
(b) Eligible for external review;
(c) Not complete, in which case the health carrier shall include
in the notice the information or materials tha t are needed to make
the request complete; or
(d) Not eligible for external review, in which case the health
carrier shall include in the notice the reasons for its ineligibility.
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14. The Commissioner may specify the form for the notice of
initial determination pursuant to subsection 13 and any supporting
information to be included in the notice.
15. The notice of initial determination must include a statement
informing the covered person and, if applicable, the covered
person’s authorized representati ve that a health carrier’s initial
determination that a request which is ineligible for external review
may be appealed to the Office for Consumer Health Assistance.
16. The Office for Consumer Health Assistance may determine
that a request is eligible f or external review pursuant to subsection
12 and require that it be referred for external review notwithstanding
a health carrier’s initial determination that the request is ineligible.
17. In making a determination pursuant to subsection 16, the
decision of the Office for Consumer Health Assistance must be
made in accordance with the terms of the covered person’s health
benefit plan and is subject to all applicable provisions of the external
review process.
18. When a health carrier determines that a r equest is eligible
for external review pursuant to subsection 12, the health carrier shall
notify the Office for Consumer Health Assistance and the covered
person and, if applicable, the covered person’s authorized
representative.
19. Within 1 business d ay after receipt of the notice from the
health carrier that the external review request is eligible for external
review pursuant to subsection 18, the Office for Consumer Health
Assistance shall:
(a) Assign an independent review organization from the list of
approved independent review organizations compiled and
maintained by the Commissioner pursuant to NRS 683A.3715 to
conduct the external review;
(b) Notify the health carrier of the name of the assigned
independent review organization; and
(c) Notify in writing the covered person and, if applicable, the
covered person’s authorized representative that the request is
eligible for external review and provide the name of the assigned
independent review organization.
20. The Office for Consumer Health Assistance shall include in
the notice provided to the covered person and, if applicable, the
covered person’s authorized representative pursuant to subsection
19 a statement that the covered person or the covered person’s
authorized representative may submi t in writing to the assigned
independent review organization within 5 business days after receipt
of the notice provided pursuant to subsection 19 additional
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information that the independent review organization shall consider
when conducting the external r eview. The independent review
organization may accept and consider additional information
submitted after the 5 business days have elapsed.
21. Within 1 business day after receipt of the notice of
assignment to conduct the external review pursuant to sub section
19, the assigned independent review organization shall:
(a) Select one or more clinical reviewers to conduct the external
review, as it determines is appropriate; and
(b) Based on the opinion of the clinical reviewer, or opinions if
more than one clinical reviewer has been selected to conduct the
external review, make a decision to uphold or reverse the adverse
determination.
22. In selecting clinical reviewers pursuant to paragraph (a) of
subsection 21, the assigned independent review organizat ion shall
select health care professionals who meet the minimum
qualifications described in NRS 683A.372 and through clinical
experience in the past 3 years, are experts in the treatment of the
covered person’s condition and knowledgeable about the
recommended or requested health care service or treatment.
23. The covered person, the covered person’s authorized
representative, if applicable, and the health carrier may not choose
or control the choice of the health care professionals to be selected
to conduct the external review.
24. In accordance with subsections 37 to 41, inclusive, each
clinical reviewer shall provide a written opinion to the assigned
independent review organization regarding whether the
recommended or requested health care service or treatment should
be covered.
25. In reaching an opinion, clinical reviewers are not bound by
any decisions or conclusions reached during the health carrier’s
utilization review process as set forth in NRS 683A.375 to
683A.379, inclusive, or the health ca rrier’s internal grievance
process as set forth in NRS 695G.200 to 695G.230, inclusive.
26. Within 5 business days after receipt of the notice pursuant
to subsection 19, the health carrier or utilization review organization
shall provide to the assigned independent review organization any
documents and information considered in making the adverse
determination.
27. Except as otherwise provided in subsection 28, failure by
the health carrier or utilization review organization to provide the
documents and information within the time specified in subsection
26 must not delay the conduct of the external review.
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28. If the health carrier or utilization review organization fails
to provide the documents and information within the time specified
in subsection 26, the assigned independent review organization may
terminate the external review and make a decision to reverse the
adverse determination.
29. If the independent review organization elects to terminate
the external review and reverse the adverse deter mination pursuant
to subsection 28, the independent review organization shall
immediately notify the covered person, the covered person’s
authorized representative, if applicable, the health carrier and the
Office for Consumer Health Assistance.
30. Each clinical reviewer selected pursuant to subsection 21
shall review all the information and documents received pursuant to
subsections 20 and 26.
31. The assigned independent review organization shall
forward any information submitted by the covered perso n or the
covered person’s authorized representative pursuant to subsection
20 to the health carrier within 1 business day after receipt of the
information.
32. Upon receipt of the information required to be forwarded
pursuant to subsection 31, the health carrier may reconsider the
adverse determination that is the subject of the external review.
33. Reconsideration by the health carrier of its adverse
determination pursuant to subsection 32 must not delay or terminate
the external review.
34. Except as otherwise provided in subsection 28, the external
review may only be terminated before completion if the health
carrier decides, upon completion of its reconsideration, to reverse its
adverse determination and provide coverage or payment for the
recommended or requested health care service or treatment that is
the subject of the adverse determination.
35. If the health carrier reverses its adverse determination
pursuant to subsection 28, the health carrier shall immediately notify
the covered person, th e covered person’s authorized representative,
if applicable, the assigned independent review organization and the
Office for Consumer Health Assistance in writing of its decision.
36. The assigned independent review organization shall
terminate the exter nal review upon receipt of the notice from the
health carrier pursuant to subsection 35.
37. Except as otherwise provided in subsection 39, within 20
days after being selected in accordance with subsection 21 to
conduct the external review, each clinical reviewer shall provide an
opinion to the assigned independent review organization pursuant to
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subsection 41 regarding whether the recommended or requested
health care service or treatment should be covered.
38. Except for an opinion provided pursuant to subsection 39,
each clinical reviewer’s opinion must be in writing and include the
following:
(a) A description of the covered person’s medical condition;
(b) A description of the indicators relevant to determine if there
is sufficient evidence to demon strate that the recommended or
requested health care service or treatment is more likely to be
beneficial to the covered person than any available standard health
care services or treatments and the adverse risks of the
recommended or requested health care service or treatment would
not be substantially increased over those of available standard health
care services or treatments;
(c) A description and analysis of any medical or scientific
evidence considered in reaching the opinion;
(d) A description and analysis of any evidence -based standards
used as a basis for the opinion; and
(e) Information concerning whether the reviewer’s rationale for
the opinion is based on the provisions of subsection 41.
39. For an expedited external review, each clinical r eviewer
shall provide an opinion orally or in writing to the assigned
independent review organization as expeditiously as the covered
person’s medical condition or circumstances requires, but in no
event not more than 5 calendar days after being selected i n
accordance with subsection 21.
40. If the opinion provided pursuant to subsection 39 was not
in writing, within 48 hours after providing that notice, the clinical
reviewer shall provide written confirmation of the opinion to the
assigned independent re view organization and include the
information required pursuant to subsection 38.
41. In addition to the documents and information provided
pursuant to subsections 10 and 26, each clinical reviewer, to the
extent the information or documents are availabl e and the reviewer
considers them appropriate, shall consider the following in reaching
an opinion:
(a) The covered person’s medical records;
(b) The attending health care professional’s recommendation;
(c) Consulting reports from appropriate health care professionals
and other documents submitted by the health carrier, covered
person, the covered person’s authorized representative or the
covered person’s treating provider;
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- 83rd Session (2025)
(d) The terms of coverage under the covered person’s health
benefit plan with th e health carrier to ensure that, but for the
health carrier’s determination that the recommended or requested
health care service or treatment that is the subject of the opinion is
experimental or investigational, the reviewer’s opinion is not
contrary to the terms of coverage under the health benefit plan; and
(e) Whether:
(1) The recommended or requested health care service or
treatment has been approved by the Food and Drug Administration,
if applicable, for the condition; or
(2) Medical or scienti fic evidence or evidence -based
standards demonstrate that the expected benefits of the
recommended or requested health care service or treatment is more
likely to be beneficial to the covered person than any available
standard health care services or treat ments and the adverse risks of
the recommended or requested health care service or treatment
would not be substantially increased over those of available standard
health care services or treatments.
42. Except as otherwise provided in subsection 43, with in 20
days after receipt of the opinion of each clinical reviewer pursuant
to subsection 41, the assigned independent review organization, in
accordance with subsection 45 or 46, shall make a decision and
provide written notice of the decision to the cover ed person, the
covered person’s authorized representative, if applicable, the health
carrier and the Office for Consumer Health Assistance and include
the information required pursuant to subsection 50.
43. For an expedited external review, within 48 hou rs after
receipt of the opinion of each clinical reviewer pursuant to
subsection 41, the assigned independent review organization, in
accordance with subsection 45 or 46, shall make a decision and
provide notice of the decision orally or in writing to the covered
person, the covered person’s authorized representative, if applicable,
the health carrier and the Office for Consumer Health Assistance.
44. If the notice provided pursuant to subsection 43 was not in
writing, within 48 hours after providing that notice, the assigned
independent review organization shall provide written confirmation
of the decision to the covered person, the covered person’s
authorized representative, if applicable, the health carrier and the
Office for Consumer Health Assistance and include the information
required pursuant to subsection 50.
45. If a majority of the clinical reviewers recommend that the
recommended or requested health care service or treatment should
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- 83rd Session (2025)
be covered, the independent review organization shall make a
decision to reverse the health carrier’s adverse determination.
46. If a majority of the clinical reviewers recommend that the
recommended or requested health care service or treatment should
not be covered, the independent review organization shall make a
decision to uphold the health carrier’s adverse determination.
47. If the clinical reviewers are evenly split as to whether the
recommended or requested health care service or treatment should
be covered, the independent review organization shall obtain the
opinion of an additional clinical reviewer in order for the
independent review organization to make a decision based on
the opinions of a majority of the clinical reviewers pursuant to
subsection 45 or 46.
48. The additional clinical reviewer selected pursuant to
subsection 47 shall use the same information to reach an opinion as
the clinical reviewers who have already submitted their opinions
pursuant to subsection 41.
49. The selection of an additional clinical reviewer pursuant to
subsection 47 must not extend the time within which the assigned
independent review organization is required to make a decision
based on the opinions of the clinical reviewers pursuant to
subsection 42.
50. The independent review organization shall include in th e
notice provided pursuant to subsection 42 or 44:
(a) A general description of the reason for the request for
external review;
(b) The written opinion of each clinical reviewer, including the
recommendation of each clinical reviewer as to whether the
recommended or requested health care service or treatment should
be covered and the rationale for the reviewer’s recommendation;
(c) The date the independent review organization was assigned
by the Office for Consumer Health Assistance to conduct the
external review;
(d) The date on which the external review was conducted;
(e) The date of the decision;
(f) The principal reason or reasons for the decision; and
(g) The rationale for the decision.
51. Upon receipt of a notice of a decision pursuant to
subsection 42 or 44 reversing the adverse determination, the health
carrier shall immediately approve coverage of the recommended or
requested health care service or treatment that was the subject of the
adverse determination.
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- 83rd Session (2025)
52. The assignment by the Offi ce for Consumer Health
Assistance of an approved independent review organization to
conduct an external review in accordance with this section must be
done on a random basis among those approved independent review
organizations qualified to conduct the par ticular external review
based on the nature of the health care service or treatment that is the
subject of the adverse determination and other circumstances,
including concerns regarding conflicts of interest pursuant to
subsection 4 of NRS 683A.372.
53. As used in this section:
(a) “Best evidence” means evidence based on:
(1) Randomized clinical trials;
(2) If randomized clinical trials are not available, cohort
studies or case-control studies;
(3) If the methods described in subparagraphs (1) and (2) are
not available, case series; or
(4) If the methods described in subparagraphs (1), (2) and (3)
are not available, expert opinion.
(b) “Evidence-based standard” means the conscientious, explicit
and judicious use of the current best evidence base d on the overall
systematic review of research in making decisions about the care of
an individual patient.
(c) “Randomized clinical trial” means a controlled, prospective
study of patients who have been randomized into an experimental
group and a control group at the beginning of the study with only
the experimental group of patients receiving a specific intervention,
which includes study of the groups for variables and anticipated
outcomes over time.
Sec. 9. NRS 695G.280 is hereby amended to read as follows:
695G.280 The decision of an independent review organization
concerning a request for an external review must be based on:
1. Documentary evidence, including any recommendation of
the physician or dentist of the insured submitted pursuant to
NRS 695G.251;
2. Medical or scientific evidence, including, without limitation:
(a) Professional standards of safety and effectiveness for
diagnosis, care and treatment that are generally recognized in the
United States;
(b) Any report published in literature that is peer-reviewed;
(c) Evidence-based medicine, including, without limitation,
reports and guidelines that are published by professional
organizations that are recognized nationally and that include
supporting scientific data; and
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- 83rd Session (2025)
(d) An opinion of an independent physician or dentist who, as
determined by the independent review organization, is an expert in
the health specialty that is the subject of the independent review;
and
3. The terms and conditions for benefits set forth in the
evidence of coverage issued to the insured by the health carrier.
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