1-4 pursuant to the provisions of sections 2 to 18, inclusive, of this act, other

1-5 than medical records and other information relating to a specific injured

2-4 1. Develop and maintain written policies and procedures setting forth

2-5 the manner in which it conducts utilization review; and

2-6 2. Require any person with whom it subcontracts to provide

2-7 utilization review to use the same policies and procedures developed

2-10 with the commissioner or the state board of health, each organization for

2-11 managed care shall file with the commissioner and the state board of

2-12 health, on or before March 1 of each year, a report regarding its methods

2-13 for reviewing the quality of medical and health care services provided to

2-14 injured employees.

2-15 2. Each organization for managed care shall include in its report the

2-16 criteria, data, benchmarks or studies used to:

2-17 (a) Assess the nature, scope, quality and accessibility of medical and

2-18 health care services provided to injured employees; or

2-19 (b) Determine any reduction or modification of the provision of

2-20 medical and health care services to injured employees.

2-21 3. Except as already required to be filed with the commissioner or

2-22 the state board of health, if the organization for managed care is not

2-23 owned and operated by a public entity and provides medical and health

2-24 care services for more than 100 injured employees, the report filed

2-25 pursuant to subsection 1 must include:

2-26 (a) A copy of all of its quarterly and annual financial reports;

2-27 (b) A statement of any financial interest it has in any other business

2-28 which is related to medical or health care that is greater than 5 percent of

2-29 that business or $5,000, whichever is less; and

2-30 (c) A description of each complaint filed with or against it that

2-31 resulted in arbitration, a lawsuit or other legal proceeding, unless

2-32 disclosure is prohibited by law or a court order.

2-33 4. A report filed pursuant to this section must be made available for

2-34 public inspection within a reasonable time after it is received by the

2-37 for an organization for managed care is responsible for such money in a

2-38 fiduciary relationship to the injured employee who is entitled to medical

2-39 and health care services and to the employer whose insurer has

2-42 coverage of a medical or health care service that has been recommended

3-22 written criteria:

3-23 (a) Setting forth the manner in which it determines whether to

3-24 authorize coverage of a medical and health care service; and

3-25 (b) Setting forth its method for reviewing standards for the quality of

3-26 medical and health care services provided to an injured employee.

3-27 2. The written criteria must be:

3-28 (a) Consistent with the standards of care for the provision of accident

3-29 benefits established by regulations adopted by the administrator pursuant

3-30 to NRS 616C.250;

3-31 (b) Developed with the assistance of practicing providers of health

3-32 care;

3-33 (c) Developed using generally recognized and, if appropriate,

3-34 specialized clinical principles and processes;

3-35 (d) Reviewed at least one time each year and, if appropriate, updated;

3-36 and

3-37 (e) Made available to an injured employee for review upon request of

3-38 the injured employee any time that the organization for managed care

3-39 denies coverage of a specific medical or health care service to the injured

4-25 quality assurance program designed to direct, evaluate and monitor the

4-26 effectiveness of medical and health care services provided to injured

4-27 employees. The program must include, without limitation:

4-28 (a) A method for analyzing the outcomes of medical and health care

4-29 services;

4-30 (b) Peer review;

4-31 (c) A system to collect and maintain information related to the

4-32 medical and health care services provided to injured employees;

4-33 (d) Recommendations for remedial action; and

4-34 (e) Written guidelines that set forth the procedures for remedial action

4-35 when problems related to quality of care are identified.

4-36 2. Each organization for managed care shall:

4-37 (a) Maintain a written description of the quality assurance program

4-38 established pursuant to subsection 1, including, without limitation, the

4-39 specific actions used by the organization for managed care to promote

4-40 adequate quality of medical and health care services provided to injured

4-41 employees and the persons responsible for such actions;

4-42 (b) Provide information to each provider of health care whom it

5-14 pursuant to section 10 of this act, each organization for managed care

5-15 shall create a quality improvement committee directed by a physician

5-16 who is licensed to practice medicine in the State of Nevada pursuant to

5-17 chapter 630 of NRS.

5-18 2. Each organization for managed care shall:

5-19 (a) Establish written guidelines setting forth the procedure for

5-20 selecting the members of the committee;

5-21 (b) Select members pursuant to such guidelines; and

5-22 (c) Provide staff to assist the committee.

5-23 3. The committee shall:

5-24 (a) Select and review appropriate medical records of injured

5-25 employees and other data related to the quality of medical and health

5-26 care provided to injured employees by providers of health care;

5-27 (b) Review the clinical processes used by providers of health care in

5-28 providing services;

5-29 (c) Identify any problems related to the quality of health care provided

5-30 to injured employees; and

5-31 (d) Advise providers of health care regarding issues related to quality

5-34 system for resolving complaints of an injured employee concerning:

5-35 (a) Payment or reimbursement for medical and health care services;

5-36 (b) Availability, delivery or quality of medical and health care

5-37 services, including, without limitation, an adverse determination made

5-38 pursuant to utilization review; or

5-39 (c) The terms and conditions of a plan for managed care.

5-40 The system must be approved by the commissioner in consultation with

5-41 the state board of health.

5-42 2. If an injured employee makes an oral complaint, an organization

6-19 section 12 of this act must include, without limitation:

6-20 (a) An initial investigation;

6-21 (b) A review of the complaint by a review board;

6-22 (c) A procedure for appealing a determination regarding the

6-23 complaint; and

6-24 (d) A clear description of what constitutes a final determination

6-25 pursuant to the system for resolving complaints.

6-26 2. The majority of the members of the review board must be injured

6-27 employees who receive medical and health care services from the

6-28 organization for managed care.

6-29 3. Except as otherwise provided in subsection 4, a review board shall

6-30 complete its review regarding a complaint or appeal and notify the

6-31 injured employee of its determination not later than 14 days after the

6-32 complaint or appeal is filed, unless the injured employee and the review

6-33 board have agreed to a longer period of time.

6-34 4. If a complaint involves an imminent and serious threat to the

6-35 health of the injured employee, the organization for managed care shall

6-36 inform the injured employee immediately of his right to an expedited

6-37 review of his complaint. If an expedited review is required, the review

6-38 board shall notify the injured employee in writing of its determination

6-39 within 72 hours after the complaint is filed. Notwithstanding the

6-40 provisions of NRS 616C.370, a determination of the review board made

6-41 pursuant to this subsection constitutes a final determination for purposes

7-7 commissioner and the state board of health an annual report regarding

7-8 its system for resolving complaints established pursuant to section 12 of

7-9 this act on a form prescribed by the commissioner in consultation with

7-10 the state board of health that includes, without limitation:

7-11 (a) A description of the procedures used for resolving complaints of

7-12 an injured employee;

7-13 (b) The total number of complaints and appeals handled through the

7-14 system for resolving complaints since the last report and a compilation of

7-15 the causes underlying the complaints filed;

7-16 (c) The current status of each complaint and appeal filed; and

7-17 (d) The average amount of time that was needed to resolve a

7-18 complaint and an appeal, if any.

7-19 2. Each organization for managed care shall maintain records of

7-20 complaints filed with it that concern something other than medical or

7-21 health care services and shall submit to the commissioner a report

7-22 summarizing those complaints at such times and in such format as the

7-25 organization for managed care shall provide written notice to an injured

7-26 employee, in clear and comprehensible language that is understandable

7-27 to an ordinary layperson, explaining the right of the injured employee to

7-28 file a written complaint and to obtain an expedited review pursuant to

7-29 section 13 of this act. The notice must be provided to an injured

7-30 employee:

7-31 (a) At the time he is hired by the employer whose insurer has

7-32 contracted with the organization for managed care;

7-33 (b) Any time that the organization for managed care denies coverage

7-34 of a medical or health care service or limits coverage of a medical or

7-35 health care service to an injured employee; and

7-36 (c) Any other time deemed necessary by the commissioner.

7-37 2. Any time that an organization for managed care denies coverage

7-38 of a medical or health care service to an injured employee it shall notify

7-39 the injured employee in writing of:

7-40 (a) The reason for denying coverage of the service;

7-41 (b) The criteria by which the organization for managed care or

7-42 insurer determines whether to authorize or deny coverage of the medical

8-6 interfere with any communication between a provider of health care and

8-7 an injured employee regarding any information that the provider of

8-8 health care determines is relevant to the health care of the injured

8-11 contract with, demote, refuse to contract with or refuse to compensate a

8-12 provider of health care solely because the provider, in good faith:

8-13 1. Advocates in private or in public on behalf of an injured

8-14 employee;

8-15 2. Assists an injured employee in seeking reconsideration of a

8-16 determination by the organization for managed care to deny coverage for

8-17 a medical or health care service; or

8-20 pay any type of material inducement, bonus or other financial incentive

8-21 to a provider of health care to deny, reduce, withhold, limit or delay

8-22 specific medically necessary medical or health care services to an injured

8-23 employee.

8-24 2. The provisions of this section do not prohibit an arrangement for

8-25 payment between an organization for managed care and a provider of

8-26 health care that uses capitation or other financial incentives, if the

8-27 arrangement is designed to provide an incentive to the provider of health

8-28 care to use medical and health care services effectively and consistently

8-32 manager may enter into a contract or contracts with one or more

8-33 organizations for managed care, including health maintenance

8-34 organizations, to provide comprehensive medical and health care services

8-35 to injured employees whose employers are insured by the system for

8-36 injuries and diseases that are compensable under chapters 616A to 617,

8-37 inclusive, of NRS. The contract or contracts must be awarded pursuant to

8-38 reasonable competitive bidding procedures as established by the manager.

8-39 2. After the selection of an organization for managed care, the bids

8-40 received by the manager and the records related to the bidding are subject

8-41 to review by any member of the public upon request.

8-42 3. An organization for managed care or a health maintenance

9-9 public or private employers or a private carrier may:

9-10 1. Enter into a contract or contracts with one or more organizations for

9-11 managed care to provide comprehensive medical and health care services

9-12 to employees for injuries and diseases that are compensable pursuant to

9-13 chapters 616A to 617, inclusive, of NRS.

9-14 2. Enter into a contract or contracts with providers of health care,

9-15 including, without limitation, physicians who provide primary care,

9-16 specialists, pharmacies, physical therapists, radiologists, nurses, diagnostic

9-17 facilities, laboratories, hospitals and facilities that provide treatment to

9-18 outpatients, to provide medical and health care services to employees for

9-19 injuries and diseases that are compensable pursuant to chapters 616A to

9-20 617, inclusive, of NRS.

9-21 3. Use the services of an organization for managed care that has

9-22 entered into a contract with the manager pursuant to NRS 616B.515, but is

9-23 not required to use such services.

9-24 4. Require employees to obtain medical and health care services for

9-25 their industrial injuries from those organizations and persons with whom

9-26 the self-insured employer, association or private carrier has contracted

9-27 pursuant to subsections 1 and 2, or as the self-insured employer,

9-28 association or private carrier otherwise prescribes.

9-29 5. [Require] Except as otherwise provided in section 9 of this act,

9-30 require employees to obtain the approval of the self-insured employer,

9-31 association or private carrier before obtaining medical and health care

9-32 services for their industrial injuries from a provider of health care who has

9-33 not been previously approved by the self-insured employer, association or

9-34 private carrier.

9-35 6. An organization for managed care with whom a self-insured

9-36 employer, association of self-insured public or private employers or a

9-37 private carrier has contracted pursuant to this section shall comply with

9-41 person who is aggrieved by a [decision] final determination concerning

9-42 accident benefits made by an organization for managed care which has

10-23 relating to a claim for compensation may appeal from the decision by

10-24 filing a notice of appeal with an appeals officer within 30 days after the

10-25 date of the decision.

10-26 2. If a dispute is required to be submitted to a procedure for resolving

10-27 complaints pursuant to NRS 616C.305 and:

10-28 (a) A final [decision] determination was rendered pursuant to that

10-29 procedure; or

10-30 (b) The dispute was not resolved pursuant to that procedure within [14]

10-31 30 days after it was submitted [,] or the longer period agreed to by an

10-32 injured employee and the review board pursuant to section 13 of this
10-33 act,

10-34 any party to the dispute may file a notice of appeal within 70 days after the

10-35 date on which the final [decision] determination was mailed to the

10-36 employee, or his dependent, or the unanswered request for resolution was

10-37 submitted. Failure to render a written [decision] determination within 30

10-38 days after receipt of such a request , or the longer period agreed to by an

10-39 injured employee and the review board pursuant to section 13 of this act,

10-40 shall be deemed by the appeals officer to be a denial of the request.

10-41 3. Except as otherwise provided in NRS 616C.380, the filing of a

10-42 notice of appeal does not automatically stay the enforcement of the