Nev. Rev. Stat. ch. 695G – Managed Care | Midpage

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Nevada Revised Statutes

Chapter 695G

Nev. Rev. Stat. ch. 695G

Managed Care

695G.010Definitions 695G.012“Adverse determination” defined 695G.014“Authorized representative” defined 695G.015“Benefits” defined 695G.016“Clinical peer” defined 695G.017“Covered person” defined 695G.019“Health benefit plan” defined 695G.020“Health care plan” defined 695G.022“Health care services” defined 695G.024“Health carrier” defined 695G.026“Independent review organization” defined 695G.030“Insured” defined 695G.040“Managed care” defined 695G.050“Managed care organization” defined 695G.053“Medical or scientific evidence” defined 695G.055“Medically necessary” defined 695G.060“Primary care physician” defined 695G.070“Provider of health care” defined 695G.080“Utilization review” defined 695G.085“Utilization review organization” defined 695G.090Applicability of chapter and other provisions 695G.095Offering policy of health insurance for purposes of establishing health savings account 695G.100Documents filed with Commissioner treated as public record; exception 695G.110Medical director required to be physician licensed in this State 695G.120Utilization review: Development and maintenance of written policies and procedures for use by managed care organization and subcontractors 695G.125Contracts with certain federally qualified health centers 695G.127Contracts 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 695G.130Report regarding methods for reviewing quality of health care services: Form of report; availability for public inspection 695G.140Certain persons in managed care organization in fiduciary relationship to insured 695G.150Authorization of recommended and covered health care services required 695G.155Managed 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 695G.160Written criteria concerning coverage of health care services and standards for quality of health care services 695G.162Required 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 695G.163Plan covering prescription drugs: Provision of notice and information regarding use of formulary 695G.1635Plan 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 695G.1639Plan 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 695G.164Required provision in certain plans concerning coverage for continued medical treatment; exceptions; regulations 695G.1643Required provision concerning coverage for habilitative speech-language pathology or rehabilitative speech-language pathology as treatment for stuttering for certain persons; prohibited acts 695G.1645Required provision in plan for group coverage concerning coverage for autism spectrum disorders for certain persons; prohibited acts 695G.166Plan covering prescription drugs prohibited from limiting or excluding coverage for prescription drug previously approved for medical condition of insured; exceptions 695G.1662Limitation on cost-sharing obligation for insulin covered under plan covering prescription insulin drugs 695G.1665Required provision in plan covering prescription drugs concerning coverage for prescription drugs irregularly dispensed for purpose of synchronization of chronic medications; prohibited acts; exception 695G.167Plan covering treatment of cancer through use of chemotherapy: Prohibited acts related to orally administered chemotherapy 695G.1675Plan 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 695G.1678Required provision in plan covering treatment of lung cancer concerning coverage for screening for lung cancer 695G.168Required provision in plan covering treatment of colorectal cancer concerning coverage for colorectal cancer screening 695G.170Required provision concerning coverage for medically necessary emergency services at any hospital; prohibited acts 695G.1702Plan covering prescription drugs: Submission to step therapy protocol for drug to treat psychiatric condition prohibited in certain circumstances 695G.1703Required 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 695G.1705Required 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 695G.1707Required provision concerning coverage for testing, treatment and prevention of sexually transmitted diseases; required provision concerning coverage for condoms for certain insureds 695G.1709Required 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 695G.171Required provision concerning coverage for certain tests and vaccines relating to human papillomavirus; prohibited acts 695G.1712Required provision concerning coverage for screening, genetic counseling and testing related to BRCA gene in certain circumstances 695G.1713Required provision concerning coverage for certain screenings and tests for breast cancer; prohibited acts 695G.1714Required provision concerning coverage for examination of person who is pregnant for certain diseases 695G.17145Required provision concerning coverage for noninvasive prenatal screening in certain plans 695G.1715Required provision concerning coverage for drug or device for contraception and related health services; prohibited acts; exceptions 695G.1716Health 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 695G.1717Required provision concerning coverage for certain services, screenings and tests relating to wellness; prohibited acts 695G.1718Required 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 695G.1719Required 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 695G.172Plan covering prescription drugs: Denial of coverage prohibited for early refills of otherwise covered topical ophthalmic products 695G.173Required 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 695G.174Required 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 695G.175Contracts 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 695G.176Plan 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 695G.1765Required provision concerning coverage for dental service provided by qualified dental hygienist in certain circumstances 695G.177Required provision in plans covering treatment of prostate cancer concerning coverage for prostate cancer screening; prohibited acts 695G.180Quality assurance program: Requirements; written description; informing providers; necessary staff; review; responsibility for activities 695G.190Quality improvement committee: Administration; duties 695G.200Establishment; approval; requirements; assistance for persons filing complaints; examination 695G.210Review board; appeal; right to expedited review of complaint; notice to insured 695G.220Annual report; managed care organization required to maintain records of and report complaints concerning something other than health care services 695G.230Written 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 695G.241Circumstances under which adverse determination may be subject to external review; exceptions 695G.243Applicability 695G.245Written notice of right to request external review; form; contents 695G.247Requests for external review to be in writing; exception; form and content 695G.251Request for review; assignment of independent review organization; provision of documents relating to adverse determination to independent review organization 695G.261Review of documents by independent review organization; decision of independent review organization 695G.271Expedited approval or denial of request 695G.275Experimental or investigational health care service or treatment: Request for external review; request for expedited external review 695G.280Basis for decision of independent review organization 695G.290Decision in favor of covered person binding on health carrier; limitation of liability; cost for independent review organization 695G.300Submission of complaint of covered person to independent review organization 695G.303Independent review organization and health carrier required to maintain written records; submission of report upon request 695G.307Health carrier required to provide description of external review procedures; format; contents 695G.310Annual report; requirements 695G.320Provision 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 695G.325Provision 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 695G.330Provision 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 695G.340Approval 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 695G.400Managed care organization prohibited from restricting or interfering with certain communications between provider of health care and patient 695G.405Managed care organization prohibited from denying coverage solely because applicant or insured was intoxicated or under the influence of controlled substance; exceptions 695G.410Managed care organization prohibited from taking certain actions against provider solely because provider advocates on behalf of patient, assists patient or reports violation of law 695G.415Managed care organization prohibited from discriminating against person with respect to participation or coverage on basis of gender identity or expression 695G.420Managed care organization prohibited from offering or paying financial incentive to provider to deny, reduce, withhold, limit or delay medically necessary services