695G.251 - Request for review; assignment of external review organization; provision of documents relating to adverse determination to external review organization.
695G.251 Request for review; assignment of external review organization; provision of documents relating to adverse determination to external review organization.
1. If an insured or a physician of an insured receives notice of a final adverse determination from a managed care organization concerning the insured, and if the insured is required to pay $500 or more for the health care services that are the subject of the final adverse determination, the insured, the physician of the insured or an authorized representative may, within 60 days after receiving notice of the final adverse determination, submit a request to the managed care organization for an external review of the final adverse determination.
2. Within 5 days after receiving a request pursuant to subsection 1, the managed care organization shall notify the insured, the authorized representative or physician of the insured, the agent who performed utilization review for the managed care organization, if any, and the Office for Consumer Health Assistance that the request has been filed with the managed care organization.
3. As soon as practicable after receiving a notice pursuant to subsection 2, the Office for Consumer Health Assistance shall assign an external review organization from the list maintained pursuant to NRS 683A.371. 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 external review organization assigned pursuant to subsection 3, the managed care organization shall provide to the external review organization all documents and materials relating to the final adverse determination, including, without limitation:
(a) Any medical records of the insured relating to the external review;
(b) A copy of the provisions of the health care plan upon which the final adverse determination was based;
(c) Any documents used by the managed care organization to make the final adverse determination;
(d) The reasons for the final adverse determination; and
(e) Insofar as practicable, a list that specifies each provider of health care who has provided health care to the insured and the medical records of the provider of health care relating to the external review.
(Added to NRS by 2003, 780)