Nevada Revised Statutes
Chapter 695G - Managed Care
NRS 695G.012 - "Adverse determination" defined.

"Adverse determination" means a determination by a health carrier or utilization review organization that an admission, availability of care, continued stay or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and the requested service or payment for the service is therefore denied, reduced or terminated.
(Added to NRS by 2003, 779; A 2011, 3410)

Structure Nevada Revised Statutes

Nevada Revised Statutes

Chapter 695G - Managed Care

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...

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 and in same amount as though provided in person or by other means; exception; prohibited acts. [Effective through 1 year after the date on w...

NRS 695G.163 - Plan covering prescription drugs: Provision of notice and information regarding use of formulary.

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.164 - Required provision in certain plans concerning coverage for continued medical treatment; exceptions; regulations.

NRS 695G.1645 - Required provision in plan for group coverage concerning coverage for autism spectrum disorders for certain persons; prohibited acts.

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.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.167 - Plan covering treatment of cancer through use of chemotherapy: Prohibited acts related to orally administered chemotherapy.

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 pr...

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.1705 - Required provision concerning coverage for drugs, laboratory testing and certain services related to human immunodeficiency virus; reimbursement of pharmacist for certain services.

NRS 695G.171 - Required provision concerning coverage for certain tests and vaccines relating to human papillomavirus; prohibited acts.

NRS 695G.1712 - Required provision concerning coverage for screening, genetic counseling and testing related to BRCA gene in certain circumstances. [Effective January 1, 2022.]

NRS 695G.1713 - Required provision concerning coverage for mammograms for certain women; 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. [Effective through December 31, 2021.] Required provision concerning coverage for drug or device for...

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.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; immuni...

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...

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 Department of Health and Human Services obtains waiver to provide dental care to persons with diabetes; coordination to ensure receipt of such care.

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.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.430 - Contracts between managed care organization and provider of health care: Form for obtaining information on provider of health care; modification; schedule of fees.