695G.241 - Adverse determination deemed final for purpose of submitting to external review organization.
695G.241 Adverse determination deemed final for purpose of submitting to external review organization.
1. For the purposes of NRS 695G.200 to 695G.310, inclusive, an adverse determination is final if the insured has exhausted all procedures set forth in the health care plan for reviewing the adverse determination within the managed care organization.
2. An adverse determination shall be deemed final for the purpose of submitting the adverse determination to an external review organization for an external review:
(a) If an insured exhausts all procedures set forth in the health care plan for reviewing the adverse determination within the managed care organization and the managed care organization fails to render a decision within the period required to render that decision set forth in the health care plan; or
(b) If the managed care organization submits the adverse determination to the external review organization without requiring the insured to exhaust all procedures set forth in the health care plan for reviewing the adverse determination within the managed care organization.
(Added to NRS by 2003, 780)