EXPLANATION – Matter in bolded italics is new; matter between brackets [omitted material] is material to be omitted. Green numbers along left margin indicate location on the printed bill (e.g., 5-15 indicates page 5, line 15).

1-1 Section 1. Chapter 679B of NRS is hereby amended by adding

1-2 thereto the provisions set forth as sections 2 to 19, inclusive, of this act.

1-3 Sec. 2. As used in sections 2 to 19, inclusive, of this act, unless the

1-6 sections.

1-7 Sec. 3. "Health care plan" means a policy, contract, certificate or

1-9 for, pay for, or reimburse any of the costs of, health care services.

1-10 Sec. 4. "Insured" means an individual who receives benefits under a

1-11 health care plan.

2-1 Sec. 5. "Insurer" means any insurer or organization authorized

2-9 organization.

2-10 Sec. 6. "Managed care organization" has the meaning ascribed to it

2-11 in NRS 695G.050.

2-12 Sec. 7. "Primary care physician" means a physician who:

2-15 3. May refer the insured to a specialized provider of health care.

2-16 Sec. 8. "Provider of health care" has the meaning ascribed to it in

2-17 NRS 629.031.

2-18 Sec. 9. "Review panel" means the external panel for the review of

2-19 denials of benefits or treatment under a health care plan.

2-20 Sec. 10. 1. The commissioner shall appoint an external panel for

2-21 the review of denials of benefits or treatment under a health care plan.

2-22 The review panel consists of three members, who must be employees of

2-23 the division or other interested persons.

2-24 2. The review panel shall hear appeals of denials by insurers of

2-25 benefits or treatment under health care plans. For each such appeal, the

2-26 division may enter into a contract with:

2-27 (a) A medical director of a managed care organization in this state;

2-28 and

2-29 (b) A primary care physician who is licensed pursuant to chapter 630

2-30 of NRS to practice medicine in this state,

2-31 to advise the review panel concerning the appeal.

2-32 3. As a condition of membership on the review panel, and as a

2-33 condition of any contract entered into with a medical director or primary

2-34 care physician to advise the review panel, the member, medical director

2-35 or primary care physician must not have any conflict of interest or

2-36 appear to have any conflict of interest in the performance of his duties as

2-37 a member of, or an adviser to, the review panel.

2-38 Sec. 11. 1. An insured may, pursuant to sections 2 to 19, inclusive,

2-39 of this act, appeal the denial by an insurer of benefits or treatment under

2-40 a health care plan to the review panel if:

2-41 (a) The cost of the benefits or treatment denied is $100 or more; and

2-42 (b) Except as otherwise provided in this paragraph, the insured has

2-43 exhausted the grievance procedures established by the insurer to

3-1 challenge the denial of benefits or treatment. The commissioner may

3-2 waive this requirement if the life of the insured is in imminent or

3-3 emergent jeopardy.

3-4 2. An appeal of a denial of benefits or treatment may be brought by:

3-5 (a) The insured;

3-6 (b) His legal guardian or legal representative; or

3-7 (c) His provider of health care.

3-8 3. Except as otherwise provided in this subsection, an appeal of a

3-9 denial of benefits or treatment must include a nonrefundable filing fee of

3-10 $25 payable to the division. The commissioner shall waive the filing fee if

3-11 he determines that the person filing the request is indigent or otherwise

3-12 cannot afford the fee.

3-13 Sec. 12. An insurer shall, as a part of its grievance procedures

3-14 established to challenge the denial of benefits or treatment, provide

3-15 notification to the insured of his right to appeal a denial of benefits or

3-16 treatment to the review panel. The notification must include information

3-17 on the procedure for making such an appeal.

3-18 Sec. 13. 1. The review panel shall conduct a full review of each

3-19 appeal of a denial of benefits or treatment by an insurer to determine

3-20 whether, as a result of the denial of benefits or treatment, the insured

3-21 was deprived of any service or treatment that was medically necessary.

3-22 The insured and the insurer may present evidence, and the review panel

3-23 may examine witnesses. The review panel may consider any pertinent

3-24 information submitted to it, including, without limitation, medical

3-25 records, practice guidelines and clinical protocols.

3-26 2. Except as otherwise provided in subsection 3, the review panel

3-27 shall approve, modify or reverse the decision of the insurer to deny the

3-28 benefits or treatment within 30 days after the date on which the appeal

3-29 was filed.

3-30 3. If the life of the insured is in imminent or emergent jeopardy, the

3-31 commissioner shall convene the review panel within 24 hours after

3-32 receiving the request for the appeal and the review panel shall approve,

3-33 modify or reverse the decision of the insurer to deny the benefits or

3-34 treatment as expediently as possible.

3-35 4. The decision of the review panel is a final decision that is binding

3-36 on the insured and the insurer.

3-37 Sec. 14. If the review panel finds in favor of the insured, the insurer

3-38 shall pay to the division the cost of the appeal not later than 45 days after

3-39 the date on which the review panel issues its finding. The division shall,

3-40 by regulation, establish a reasonable fee to be charged pursuant to this

3-41 section to pay for the cost of an appeal before the review panel.

4-1 Sec. 15. In an appeal before the review panel, an insured or insurer

4-2 may be represented by legal counsel or any other person whom the

4-3 insured or insurer, as appropriate, chooses. An insured or insurer who

4-4 uses an attorney or other person to represent the insured or insurer, as

4-5 appropriate, before the review panel is responsible for any attorney’s fees

4-6 or other fees charged by his attorney or representative. The insured and

4-7 insurer are not required to attend any hearing held by the review panel

4-8 on the appeal.

4-9 Sec. 16. The review panel, and any medical director and primary

4-10 care physician advising the review panel, shall, to the extent required by

4-11 law, preserve the confidentiality of medical records that are submitted to

4-12 the review panel, unless the insured, or his legal guardian or legal

4-13 representative gives written consent to the disclosure of the records.

4-14 Sec. 17. A member of the review panel, and any medical director

4-15 and primary care physician advising the review panel, is not liable in a

4-16 civil action for any act that he performs in good faith in the execution of

4-17 his duties pursuant to sections 2 to 19, inclusive, of this act.

4-18 Sec. 18. On or before January 1 of each year, the commissioner

4-19 shall:

4-20 1. Compile a report of the number of appeals made to the review

4-21 panel during the previous calendar year and the outcomes of those

4-22 appeals; and

4-23 2. Submit the report to:

4-24 (a) The governor; and

4-25 (b) The director of the legislative counsel bureau for transmittal to the

4-26 appropriate legislative committees.

4-27 Sec. 19. The division shall adopt such regulations as are necessary

4-28 to carry out the provisions of sections 2 to 19, inclusive, of this act.