616A.469 - Certificate to operate as external review organization: Authority of Commissioner to issue certificate; application; fee; prerequisites to issuance; ineligible parties.
616A.469 Certificate to operate as external review organization: Authority of Commissioner to issue certificate; application; fee; prerequisites to issuance; ineligible parties.
1. The Commissioner may issue certificates authorizing qualified external review organizations to conduct external reviews for the purposes of chapters 616A to 617, inclusive, of NRS. If the Commissioner issues such certificates and the Commissioner determines that an external review organization is qualified to conduct external reviews for the purposes of chapters 616A to 617, inclusive, of NRS, the Commissioner shall issue a certificate to the external review organization that authorizes the organization to conduct such external reviews in accordance with the provisions of NRS 616C.363 and the regulations adopted by the Commissioner.
2. The Commissioner may adopt regulations setting forth the procedures that an external review organization must follow to be issued a certificate to conduct external reviews. Any regulations adopted pursuant to this section must include, without limitation, provisions setting forth:
(a) The manner in which an external review organization may apply for a certificate and the requirements for the issuance and renewal of the certificate pursuant to this section;
(b) The grounds for which the Commissioner may refuse to issue, suspend, revoke or refuse to renew a certificate issued pursuant to this section;
(c) The manner and circumstances under which an external review organization is required to conduct its business; and
(d) Any applicable fees for issuing or renewing a certificate of an external review organization pursuant to this section.
3. A certificate issued pursuant to this section expires 1 year after it is issued and may be renewed in accordance with regulations adopted by the Commissioner.
4. Before the Commissioner may issue a certificate to an external review organization, the external review organization must:
(a) Demonstrate to the satisfaction of the Commissioner that it is able to carry out, in a timely manner, the duties of an external review organization as set forth in NRS 616C.363 and the regulations adopted by the Commissioner. The demonstration must include, without limitation, proof that the external review organization employs, contracts with or otherwise retains only persons who are qualified because of their education, training, professional licensing and experience to perform the duties assigned to those persons; and
(b) Provide assurances satisfactory to the Commissioner that the external review organization will:
(1) Conduct external reviews in accordance with the provisions of NRS 616C.363 and the regulations adopted by the Commissioner;
(2) Render its decisions in a clear, consistent, thorough and timely manner; and
(3) Avoid conflicts of interest.
5. For the purposes of this section, an external review organization has a conflict of interest if the external review organization or any employee, agent or contractor of the external review organization who conducts an external review has a professional, familial or financial interest of a material nature with respect to any person who has a substantial interest in the outcome of the external review, including, without limitation:
(a) The claimant;
(b) The employer; or
(c) The insurer or any officer, director or management employee of the insurer.
6. The Commissioner shall not issue a certificate to an external review organization that is affiliated with:
(a) An organization for managed care which provides comprehensive medical and health care services to employees for injuries or diseases pursuant to chapters 616A to 617, inclusive, of NRS;
(b) An insurer;
(c) A third-party administrator; or
(d) A national, state or local trade association.
7. An external review organization which is certified or accredited by an accrediting body that is nationally recognized shall be deemed to have satisfied all the conditions and qualifications required for the external review organization to be issued a certificate pursuant to this section.
(Added to NRS by 2003, 2330; A 2009, 1827)