Nevada Chapter 695G — Managed Care

99 sections hosted, reproduced from the official public-domain source.

NRS 695G.010— Definitions
NRS 695G.012— “Adverse determination” defined
NRS 695G.014— “Authorized representative” defined
NRS 695G.015— “Benefits” defined
NRS 695G.016— “Clinical peer” defined
NRS 695G.017— “Covered person” defined
NRS 695G.019— “Health benefit plan” defined
NRS 695G.020— “Health care plan” defined
NRS 695G.022— “Health care services” defined
NRS 695G.024— “Health carrier” defined
NRS 695G.026— “Independent review organization” defined
NRS 695G.030— “Insured” defined
NRS 695G.040— “Managed care” defined
NRS 695G.050— “Managed care organization” defined
NRS 695G.053— “Medical or scientific evidence” defined
NRS 695G.055— “Medically necessary” defined
NRS 695G.060— “Primary care physician” defined
NRS 695G.070— “Provider of health care” defined
NRS 695G.080— “Utilization review” defined
NRS 695G.085— “Utilization review organization” defined
NRS 695G.090— Applicability of chapter and other provisions
NRS 695G.095— Offering policy of health insurance for purposes of establishing health savings account
NRS 695G.100— Documents filed with Commissioner treated as public record; exception
NRS 695G.110— Medical director required to be physician licensed in this State
NRS 695G.120— Utilization review: Development and maintenance of written policies and procedures for use by managed care organization and subcontractors
NRS 695G.125— Contracts with certain federally qualified health centers
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
NRS 695G.130— Report regarding methods for reviewing quality of health care services: Form of report; availability for public inspection
NRS 695G.140— Certain persons in managed care organization in fiduciary relationship to insured
NRS 695G.150— Authorization of recommended and covered health care services required
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
NRS 695G.160— Written criteria concerning coverage of health care services and standards for quality of health care services
NRS 695G.162— Required provision concerning coverage for services provided through telehealth to same extent as though provided in person or by other means; required provision concerning reimbursement for certain services provided through telehealth in same amount as though provided in person or by other means; prohibited acts; requirements for certain managed care organizations concerning teledentistry
NRS 695G.163— Plan covering prescription drugs: Provision of notice and information regarding use of formulary
NRS 695G.164— Required provision in certain plans concerning coverage for continued medical treatment; exceptions; regulations
NRS 695G.166— Plan covering prescription drugs prohibited from limiting or excluding coverage for prescription drug previously approved for medical condition of insured; exceptions
NRS 695G.167— Plan covering treatment of cancer through use of chemotherapy: Prohibited acts related to orally administered chemotherapy
NRS 695G.168— Required provision in plan covering treatment of colorectal cancer concerning coverage for colorectal cancer screening
NRS 695G.170— Required provision concerning coverage for medically necessary emergency services at any hospital; prohibited acts
NRS 695G.171— Required provision concerning coverage for certain tests and vaccines relating to human papillomavirus; prohibited acts
NRS 695G.172— Plan covering prescription drugs: Denial of coverage prohibited for early refills of otherwise covered topical ophthalmic products
NRS 695G.173— Required provision concerning coverage for certain treatment received as part of clinical trial or study for treatment of cancer or chronic fatigue syndrome; authority of managed care organization to require certain information; immunity from liability
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
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
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
NRS 695G.177— Required provision in plans covering treatment of prostate cancer concerning coverage for prostate cancer screening; prohibited acts
NRS 695G.180— Quality assurance program: Requirements; written description; informing providers; necessary staff; review; responsibility for activities
NRS 695G.190— Quality improvement committee: Administration; duties
NRS 695G.200— Establishment; approval; requirements; assistance for persons filing complaints; examination
NRS 695G.210— Review board; appeal; right to expedited review of complaint; notice to insured
NRS 695G.220— Annual report; managed care organization required to maintain records of and report complaints concerning something other than health care services
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
NRS 695G.241— Circumstances under which adverse determination may be subject to external review; exceptions
NRS 695G.243— Applicability
NRS 695G.245— Written notice of right to request external review; form; contents
NRS 695G.247— Requests for external review to be in writing; exception; form and content
NRS 695G.251— Request for review; assignment of independent review organization; provision of documents relating to adverse determination to independent review organization
NRS 695G.261— Review of documents by independent review organization; decision of independent review organization
NRS 695G.271— Expedited approval or denial of request
NRS 695G.275— Experimental or investigational health care service or treatment: Request for external review; request for expedited external review
NRS 695G.280— Basis for decision of independent review organization
NRS 695G.290— Decision in favor of covered person binding on health carrier; limitation of liability; cost for independent review organization
NRS 695G.300— Submission of complaint of covered person to independent review organization
NRS 695G.303— Independent review organization and health carrier required to maintain written records; submission of report upon request
NRS 695G.307— Health carrier required to provide description of external review procedures; format; contents
NRS 695G.310— Annual report; requirements
NRS 695G.320— Provision of health care services to recipients of Medicaid or enrollees in Children’s Health Insurance Program: Requirement to contract with hospital with certain endorsement for inclusion in network of providers
NRS 695G.325— Provision of health care services to recipients of Medicaid: Notice to recipients if Nevada Health Authority obtains waiver to provide dental care to persons with diabetes; coordination to ensure receipt of such care
NRS 695G.330— Provision of health care services to recipients of Medicaid: Coverage for antipsychotic or anticonvulsant medication that is not on list of preferred prescription drugs required upon failure of drug on list to treat condition
NRS 695G.340— Approval or denial; payment of claim and interest; request for additional information; award of costs and attorney’s fees; compliance with requirements; imposition of administrative fine or suspension or revocation of certificate of authority for failure to comply; report of compliance by organization
NRS 695G.400— Managed care organization prohibited from restricting or interfering with certain communications between provider of health care and patient
NRS 695G.405— Managed care organization prohibited from denying coverage solely because applicant or insured was intoxicated or under the influence of controlled substance; exceptions
NRS 695G.410— Managed care organization prohibited from taking certain actions against provider solely because provider advocates on behalf of patient, assists patient or reports violation of law
NRS 695G.415— Managed care organization prohibited from discriminating against person with respect to participation or coverage on basis of gender identity or expression
NRS 695G.420— Managed care organization prohibited from offering or paying financial incentive to provider to deny, reduce, withhold, limit or delay medically necessary services
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
NRS 695G.1639— Plan covering prescription drug for treatment of medical condition that is part of step therapy protocol: Use of certain guidelines required; establishment of process to request exemption from step therapy protocol required; granting of request; applicability of provisions
NRS 695G.1643— Required provision concerning coverage for habilitative speech-language pathology or rehabilitative speech-language pathology as treatment for stuttering for certain persons; prohibited acts
NRS 695G.1645— Required provision in plan for group coverage concerning coverage for autism spectrum disorders for certain persons; prohibited acts
NRS 695G.1662— Limitation on cost-sharing obligation for insulin covered under plan covering prescription insulin drugs
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
NRS 695G.1675— Plan covering prescription drug for treatment of cancer or cancer symptom that is part of step therapy protocol: Managed care organization required to allow insured or attending practitioner to apply for exemption from step therapy protocol in certain circumstances; procedure for applying for and granting exemption
NRS 695G.1678— Required provision in plan covering treatment of lung cancer concerning coverage for screening for lung cancer
NRS 695G.1702— Plan covering prescription drugs: Submission to step therapy protocol for drug to treat psychiatric condition prohibited in certain circumstances
NRS 695G.1703— Required provision concerning coverage for biomarker testing for diagnosis, treatment, management and monitoring of cancer in certain circumstances; establishment of process to request exception or appeal denial of coverage; time for responding to request for prior authorization
NRS 695G.1705— Required provision concerning coverage for drugs, laboratory testing and certain services related to human immunodeficiency virus and hepatitis C; reimbursement of certain providers of health care for certain services; prohibited acts
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
NRS 695G.1709— Required provisions concerning coverage of certain gynecological and obstetrical services without prior authorization or referral from primary care physician; designation of obstetrician or gynecologist as primary care physician
NRS 695G.1712— Required provision concerning coverage for screening, genetic counseling and testing related to BRCA gene in certain circumstances
NRS 695G.1713— Required provision concerning coverage for certain screenings and tests for breast cancer; prohibited acts
NRS 695G.1714— Required provision concerning coverage for examination of person who is pregnant for certain diseases
NRS 695G.1715— Required provision concerning coverage for drug or device for contraception and related health services; prohibited acts; exceptions
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
NRS 695G.1717— Required provision concerning coverage for certain services, screenings and tests relating to wellness; prohibited acts
NRS 695G.1718— Required provision concerning coverage for medically necessary treatment of conditions relating to gender dysphoria and gender incongruence; restriction on refusal to cover certain treatments; authority of managed care organization to prescribe requirements for covering surgical treatments for minors; determination of medical necessity
NRS 695G.1719— Required provision concerning coverage for certain drugs and services related to substance use disorder and opioid use disorder; reimbursement of pharmacists and pharmacies for certain services; prohibited acts
NRS 695G.1765— Required provision concerning coverage for dental service provided by qualified dental hygienist in certain circumstances
NRS 695G.17145— Required provision concerning coverage for noninvasive prenatal screening in certain plans
NRS 695G.17165— Required provision concerning coverage for procedure or service for preservation of fertility in certain circumstances; exemption. [Effective January 1, 2027.]