SB99_EN

Senate Bill No. 99–Senator O’Connell (by request)

CHAPTER..........

AN ACT relating to insurance; revising provisions governing the prompt payment by insurers of approved claims to providers of health care; revising the rate of interest applicable to the late payment of such claims; prohibiting the assessment of fees against providers of health care to be included on a list of providers of health care; establishing an administrative fine against insurers who do not substantially comply with the provisions requiring prompt payment of approved claims to providers of health care; allowing an employee who is injured or who contracts an occupational disease outside this state to receive compensation from the uninsured employers’ claim fund under certain circumstances; and providing other matters properly relating thereto.

THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN

SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS:

1-1 Section 1. NRS 679B.138 is hereby amended to read as follows:

1-2 679B.138 1. The commissioner shall adopt regulations which require

1-3 the use of uniform claim forms and billing codes and the ability to make

1-4 compatible electronic data transfers for all insurers and administrators

1-5 authorized to conduct business in this state relating to a health care plan or

1-6 health insurance or providing or arranging for the provision of health care

1-7 services, including, without limitation, an insurer that issues a policy of

1-8 health insurance, an insurer that issues a policy of group health insurance,

1-9 a carrier serving small employers, a fraternal benefit society, a hospital or

1-10 medical service corporation, a health maintenance organization, a plan for

1-11 dental care and a prepaid limited health service organization. The

1-12 regulations must include, without limitation, a uniform billing format to

1-13 be used for the submission of claims to such insurers and

1-14 administrators.

1-15 2. As used in this section:

1-16 (a) “Administrator” has the meaning ascribed to it in NRS 683A.025.

1-17 (b) “Health care plan” means a policy, contract, certificate or agreement

1-18 offered or issued by an insurer to provide, deliver, arrange for, pay for or

1-19 reimburse any of the costs of health care services.

1-20 Sec. 1.5. NRS 683A.0879 is hereby amended to read as follows:

1-21 683A.0879 1. Except as otherwise provided in subsection 2, an

1-22 administrator shall approve or deny a claim relating to health insurance

1-23 coverage within 30 days after the administrator receives the claim. If the

1-24 claim is approved, the administrator shall pay the claim within 30 days

1-25 after it is approved. [If] Except as otherwise provided in this section, if

1-26 the approved claim is not paid within that period, the administrator shall

1-27 pay interest on the claim at [the] a rate of interest [established pursuant to

1-28 NRS 99.040 unless a different rate of interest is established pursuant to an

1-29 express written contract between the administrator and the provider of

1-30 health care.] equal to the prime rate at the largest bank in Nevada, as

1-31 ascertained by the commissioner of financial institutions, on January 1

1-32 or July 1, as the case may be, immediately preceding the date on which

1-33 the payment was due, plus 6 percent. The interest must be calculated from

1-34 30 days after the date on which the claim is approved until the date on

1-35 which the claim is paid.

1-36 2. If the administrator requires additional information to determine

1-37 whether to approve or deny the claim, he shall notify the claimant of his

2-1 request for the additional information within 20 days after he receives the

2-2 claim. The administrator shall notify the provider of health care of all the

2-3 specific reasons for the delay in approving or denying the claim. The

2-4 administrator shall approve or deny the claim within 30 days after

2-5 receiving the additional information. If the claim is approved, the

2-6 administrator shall pay the claim within 30 days after he receives the

2-7 additional information. If the approved claim is not paid within that

2-8 period, the administrator shall pay interest on the claim in the manner

2-9 prescribed in subsection 1.

2-10 3. An administrator shall not request a claimant to resubmit

2-11 information that the claimant has already provided to the administrator,

2-12 unless the administrator provides a legitimate reason for the request and

2-13 the purpose of the request is not to delay the payment of the claim, harass

2-14 the claimant or discourage the filing of claims.

2-15 4. An administrator shall not pay only part of a claim that has been

2-16 approved and is fully payable.

2-17 5. A court shall award costs and reasonable attorney’s fees to the

2-18 prevailing party in an action brought pursuant to this section.

2-19 6. The payment of interest provided for in this section for the late

2-20 payment of an approved claim may be waived only if the payment was

2-21 delayed because of an act of God or another cause beyond the control of

2-22 the administrator.

2-23 7. The commissioner may require an administrator to provide

2-24 evidence which demonstrates that the administrator has substantially

2-25 complied with the requirements set forth in this section, including,

2-26 without limitation, payment within 30 days of at least 95 percent of

2-27 approved claims or at least 90 percent of the total dollar amount for

2-28 approved claims. If the commissioner determines that an administrator

2-29 is not in substantial compliance with the requirements set forth in this

2-30 section, the commissioner may require the administrator to pay an

2-31 administrative fine in an amount to be determined by the commissioner.

2-32 Sec. 2. NRS 689A.035 is hereby amended to read as follows:

2-33 689A.035 An insurer [may] shall not charge a provider of health care

2-34 a fee to include the name of the provider on a list of providers of health

2-35 care given by the insurer to its insureds. [The amount of the fee must be

2-36 reasonable and must not exceed an amount that is directly related to the

2-37 administrative costs of the insurer to include the provider on the list.]

2-38 Sec. 3. NRS 689A.410 is hereby amended to read as follows:

2-39 689A.410 1. Except as otherwise provided in subsection 2, an insurer

2-40 shall approve or deny a claim relating to a policy of health insurance

2-41 within 30 days after the insurer receives the claim. If the claim is

2-42 approved, the insurer shall pay the claim within 30 days after it is

2-43 approved. [If] Except as otherwise provided in this section, if the

2-44 approved claim is not paid within that period, the insurer shall pay interest

2-45 on the claim at [the] a rate of interest [established pursuant to NRS 99.040

2-46 unless a different rate of interest is established pursuant to an express

2-47 written contract between the insurer and the provider of health care.] equal

2-48 to the prime rate at the largest bank in Nevada, as ascertained by the

2-49 commissioner of financial institutions, on January 1 or July 1, as the

2-50 case may be, immediately preceding the date on which the payment was

2-51 due, plus 6 percent. The

3-1 interest must be calculated from 30 days after the date on which the claim

3-2 is approved until the date on which the claim is paid.

3-3 2. If the insurer requires additional information to determine whether

3-4 to approve or deny the claim, it shall notify the claimant of its request for

3-5 the additional information within 20 days after it receives the claim. The

3-6 insurer shall notify the provider of health care of all the specific reasons

3-7 for the delay in approving or denying the claim. The insurer shall approve

3-8 or deny the claim within 30 days after receiving the additional

3-9 information. If the claim is approved, the insurer shall pay the claim

3-10 within 30 days after it receives the additional information. If the approved

3-11 claim is not paid within that period, the insurer shall pay interest on the

3-12 claim in the manner prescribed in subsection 1.

3-13 3. An insurer shall not request a claimant to resubmit information that

3-14 the claimant has already provided to the insurer, unless the insurer

3-15 provides a legitimate reason for the request and the purpose of the request

3-16 is not to delay the payment of the claim, harass the claimant or discourage

3-17 the filing of claims.

3-18 4. An insurer shall not pay only part of a claim that has been approved

3-19 and is fully payable.

3-20 5. A court shall award costs and reasonable attorney’s fees to the

3-21 prevailing party in an action brought pursuant to this section.

3-22 6. The payment of interest provided for in this section for the late

3-23 payment of an approved claim may be waived only if the payment was

3-24 delayed because of an act of God or another cause beyond the control of

3-25 the insurer.

3-26 7. The commissioner may require an insurer to provide evidence

3-27 which demonstrates that the insurer has substantially complied with the

3-28 requirements set forth in this section, including, without limitation,

3-29 payment within 30 days of at least 95 percent of approved claims or at

3-30 least 90 percent of the total dollar amount for approved claims. If the

3-31 commissioner determines that an insurer is not in substantial

3-32 compliance with the requirements set forth in this section, the

3-33 commissioner may require the insurer to pay an administrative fine in

3-34 an amount to be determined by the commissioner.

3-35 Sec. 4. NRS 689B.015 is hereby amended to read as follows:

3-36 689B.015 An insurer that issues a policy of group health insurance

3-37 [may] shall not charge a provider of health care a fee to include the name

3-38 of the provider on a list of providers of health care given by the insurer to

3-39 its insureds. [The amount of the fee must be reasonable and must not

3-40 exceed an amount that is directly related to the administrative costs of the

3-41 insurer to include the provider on the list.]

3-42 Sec. 5. NRS 689B.255 is hereby amended to read as follows:

3-43 689B.255 1. Except as otherwise provided in subsection 2, an insurer

3-44 shall approve or deny a claim relating to a policy of group health insurance

3-45 or blanket insurance within 30 days after the insurer receives the claim. If

3-46 the claim is approved, the insurer shall pay the claim within 30 days after

3-47 it is approved. [If] Except as otherwise provided in this section, if the

3-48 approved claim is not paid within that period, the insurer shall pay interest

3-49 on the claim at [the] a rate of interest [established pursuant to NRS 99.040

3-50 unless a different rate of interest is established pursuant to an express

4-1 written contract between the insurer and the provider of health care.] equal

4-2 to the prime rate at the largest bank in Nevada, as ascertained by the

4-3 commissioner of financial institutions, on January 1 or July 1, as the

4-4 case may be, immediately preceding the date on which the payment was

4-5 due, plus 6 percent. The interest must be calculated from 30 days after the

4-6 date on which the claim is approved until the date on which the claim is

4-7 paid.

4-8 2. If the insurer requires additional information to determine whether

4-9 to approve or deny the claim, it shall notify the claimant of its request for

4-10 the additional information within 20 days after it receives the claim. The

4-11 insurer shall notify the provider of health care of all the specific reasons

4-12 for the delay in approving or denying the claim. The insurer shall approve

4-13 or deny the claim within 30 days after receiving the additional

4-14 information. If the claim is approved, the insurer shall pay the claim

4-15 within 30 days after it receives the additional information. If the approved

4-16 claim is not paid within that period, the insurer shall pay interest on the

4-17 claim in the manner prescribed in subsection 1.

4-18 3. An insurer shall not request a claimant to resubmit information that

4-19 the claimant has already provided to the insurer, unless the insurer

4-20 provides a legitimate reason for the request and the purpose of the request

4-21 [in] is not to delay the payment of the claim, harass the claimant or

4-22 discourage the filing of claims.

4-23 4. An insurer shall not pay only part of a claim that has been approved

4-24 and is fully payable.

4-25 5. A court shall award costs and reasonable attorney’s fees to the

4-26 prevailing party in an action brought pursuant to this section.

4-27 6. The payment of interest provided for in this section for the late

4-28 payment of an approved claim may be waived only if the payment was

4-29 delayed because of an act of God or another cause beyond the control of

4-30 the insurer.

4-31 7. The commissioner may require an insurer to provide evidence

4-32 which demonstrates that the insurer has substantially complied with the

4-33 requirements set forth in this section, including, without limitation,

4-34 payment within 30 days of at least 95 percent of approved claims or at

4-35 least 90 percent of the total dollar amount for approved claims. If the

4-36 commissioner determines that an insurer is not in substantial

4-37 compliance with the requirements set forth in this section, the

4-38 commissioner may require the insurer to pay an administrative fine in

4-39 an amount to be determined by the commissioner.

4-40 Sec. 6. NRS 689C.435 is hereby amended to read as follows:

4-41 689C.435 A carrier serving small employers and a carrier that offers a

4-42 contract to a voluntary purchasing group [may] shall not charge a provider

4-43 of health care a fee to include the name of the provider on a list of

4-44 providers of health care given by the carrier to its insureds. [The amount

4-45 of the fee must be reasonable and must not exceed an amount that is

4-46 directly related to the administrative costs of the carrier to include the

4-47 provider on the list.]

4-48 Sec. 7. NRS 689C.485 is hereby amended to read as follows:

4-49 689C.485 1. Except as otherwise provided in subsection 2, a carrier

4-50 serving small employers and a carrier that offers a contract to a voluntary

5-1 purchasing group shall approve or deny a claim relating to a policy of

5-2 health insurance within 30 days after the carrier receives the claim. If the

5-3 claim is approved, the carrier shall pay the claim within 30 days after it is

5-4 approved. [If] Except as otherwise provided in this section, if the

5-5 approved claim is not paid within that period, the carrier shall pay interest

5-6 on the claim at [the] a rate of interest [established pursuant to NRS 99.040

5-7 unless a different rate of interest is established pursuant to an express

5-8 written contract between the carrier and the provider of health care.] equal

5-9 to the prime rate at the largest bank in Nevada, as ascertained by the

5-10 commissioner of financial institutions, on January 1 or July 1, as the

5-11 case may be, immediately preceding the date on which the payment was

5-12 due, plus 6 percent. The interest must be calculated from 30 days after the

5-13 date on which the claim is approved until the date on which the claim is

5-14 paid.

5-15 2. If the carrier requires additional information to determine whether to

5-16 approve or deny the claim, it shall notify the claimant of its request for the

5-17 additional information within 20 days after it receives the claim. The

5-18 carrier shall notify the provider of health care of all the specific reasons for

5-19 the delay in approving or denying the claim. The carrier shall approve or

5-20 deny the claim within 30 days after receiving the additional information. If

5-21 the claim is approved, the carrier shall pay the claim within 30 days after it

5-22 receives the additional information. If the approved claim is not paid

5-23 within that period, the carrier shall pay interest on the claim in the manner

5-24 prescribed in subsection 1.

5-25 3. A carrier shall not request a claimant to resubmit information that

5-26 the claimant has already provided to the carrier, unless the carrier provides

5-27 a legitimate reason for the request and the purpose of the request is not to

5-28 delay the payment of the claim, harass the claimant or discourage the

5-29 filing of claims.

5-30 4. A carrier shall not pay only part of a claim that has been approved

5-31 and is fully payable.

5-32 5. A court shall award costs and reasonable attorney’s fees to the

5-33 prevailing party in an action brought pursuant to this section.

5-34 6. The payment of interest provided for in this section for the late

5-35 payment of an approved claim may be waived only if the payment was

5-36 delayed because of an act of God or another cause beyond the control of

5-37 the carrier.

5-38 7. The commissioner may require a carrier to provide evidence

5-39 which demonstrates that the carrier has substantially complied with the

5-40 requirements set forth in this section, including, without limitation,

5-41 payment within 30 days of at least 95 percent of approved claims or at

5-42 least 90 percent of the total dollar amount for approved claims. If the

5-43 commissioner determines that a carrier is not in substantial compliance

5-44 with the requirements set forth in this section, the commissioner may

5-45 require the carrier to pay an administrative fine in an amount to be

5-46 determined by the commissioner.

5-47 Sec. 8. NRS 695A.095 is hereby amended to read as follows:

5-48 695A.095 A society [may] shall not charge a provider of health care a

5-49 fee to include the name of the provider on a list of providers of health care

5-50 given by the society to its insureds. [The amount of the fee must be

6-1 reasonable and must not exceed an amount that is directly related to the

6-2 administrative costs of the society to include the provider on the list.]

6-3 Sec. 9. NRS 695B.035 is hereby amended to read as follows:

6-4 695B.035 A corporation subject to the provisions of this chapter [may]

6-5 shall not charge a provider of health care a fee to include the name of the

6-6 provider on a list of providers of health care given by the corporation to its

6-7 insureds. [The amount of the fee must be reasonable and must not exceed

6-8 an amount that is directly related to the administrative costs of the

6-9 corporation to include the provider on the list.]

6-10 Sec. 10. NRS 695B.2505 is hereby amended to read as follows:

6-11 695B.2505 1. Except as otherwise provided in subsection 2, a

6-12 corporation subject to the provisions of this chapter shall approve or deny

6-13 a claim relating to a contract for dental, hospital or medical services within

6-14 30 days after the corporation receives the claim. If the claim is approved,

6-15 the corporation shall pay the claim within 30 days after it is approved. [If]

6-16 Except as otherwise provided in this section, if the approved claim is not

6-17 paid within that period, the corporation shall pay interest on the claim at

6-18 [the] a rate of interest [established pursuant to NRS 99.040 unless a

6-19 different rate of interest is established pursuant to an express written

6-20 contract between the corporation and the provider of health care.] equal to

6-21 the prime rate at the largest bank in Nevada, as ascertained by the

6-22 commissioner of financial institutions, on January 1 or July 1, as the

6-23 case may be, immediately preceding the date on which the payment was

6-24 due, plus 6 percent. The interest must be calculated from 30 days after the

6-25 date on which the claim is approved until the date on which the claim is

6-26 paid.

6-27 2. If the corporation requires additional information to determine

6-28 whether to approve or deny the claim, it shall notify the claimant of its

6-29 request for the additional information within 20 days after it receives the

6-30 claim. The corporation shall notify the provider of dental, hospital or

6-31 medical services of all the specific reasons for the delay in approving or

6-32 denying the claim. The corporation shall approve or deny the claim within

6-33 30 days after receiving the additional information. If the claim is

6-34 approved, the corporation shall pay the claim within 30 days after it

6-35 receives the additional information. If the approved claim is not paid

6-36 within that period, the corporation shall pay interest on the claim in the

6-37 manner prescribed in subsection 1.

6-38 3. A corporation shall not request a claimant to resubmit information

6-39 that the claimant has already provided to the corporation, unless the

6-40 corporation provides a legitimate reason for the request and the purpose of

6-41 the request is not to delay the payment of the claim, harass the claimant or

6-42 discourage the filing of claims.

6-43 4. A corporation shall not pay only part of a claim that has been

6-44 approved and is fully payable.

6-45 5. A court shall award costs and reasonable attorney’s fees to the

6-46 prevailing party in an action brought pursuant to this section.

6-47 6. The payment of interest provided for in this section for the late

6-48 payment of an approved claim may be waived only if the payment was

6-49 delayed because of an act of God or another cause beyond the control of

6-50 the corporation.

7-1 7. The commissioner may require a corporation to provide evidence

7-2 which demonstrates that the corporation has substantially complied with

7-3 the requirements set forth in this section, including, without limitation,

7-4 payment within 30 days of at least 95 percent of approved claims or at

7-5 least 90 percent of the total dollar amount for approved claims. If the

7-6 commissioner determines that a corporation is not in substantial

7-7 compliance with the requirements set forth in this section, the

7-8 commissioner may require the corporation to pay an administrative fine

7-9 in an amount to be determined by the commissioner.

7-10 Sec. 11. Chapter 695C of NRS is hereby amended by adding thereto

7-11 the provisions set forth as sections 11.3 and 11.7 of this act.

7-12 Sec. 11.3. 1. A health maintenance organization shall not:

7-13 (a) Enter into any contract or agreement, or make any other

7-14 arrangements, with a provider for the provision of health care; or

7-15 (b) Employ a provider pursuant to a contract, an agreement or any

7-16 other arrangement to provide health care,

7-17 unless the contract, agreement or other arrangement specifically

7-18 provides that the health maintenance organization and provider agree to

7-19 the schedule for the payment of claims set forth in NRS 695C.185.

7-20 2. Any contract, agreement or other arrangement between a health

7-21 maintenance organization and a provider that is entered into or renewed

7-22 on or after October 1, 2001, that does not specifically include a provision

7-23 concerning the schedule for the payment of claims as required by

7-24 subsection 1 shall be deemed to conform with the requirements of

7-25 subsection 1 by operation of law.

7-26 Sec. 11.7. Any contract or other agreement entered into or renewed

7-27 by a health maintenance organization on or after October 1, 2001:

7-28 1. To provide health care services through managed care to

7-29 recipients of Medicaid under the state plan for Medicaid; or

7-30 2. With the division of health care financing and policy of the

7-31 department of human resources to provide insurance pursuant to the

7-32 children’s health insurance program,

7-33 must require the health maintenance organization to pay interest to a

7-34 provider of health care services on a claim that is not paid within the

7-35 time provided in the contract or agreement at a rate of interest equal to

7-36 the prime rate at the largest bank in Nevada, as ascertained by the

7-37 commissioner of financial institutions, on January 1 or July 1, as the

7-38 case may be, immediately preceding the date on which the payment was

7-39 due, plus 6 percent. The interest must be calculated from 30 days after

7-40 the date on which the claim is approved until the date on which the

7-41 claim is paid.

7-42 Sec. 12. NRS 695C.050 is hereby amended to read as follows:

7-43 695C.050 1. Except as otherwise provided in this chapter or in

7-44 specific provisions of this Title, the provisions of this Title are not

7-45 applicable to any health maintenance organization granted a certificate of

7-46 authority under this chapter. This provision does not apply to an insurer

7-47 licensed and regulated pursuant to this Title except with respect to its

7-48 activities as a health maintenance organization authorized and regulated

7-49 pursuant to this chapter.

8-1 2. Solicitation of enrollees by a health maintenance organization

8-2 granted a certificate of authority, or its representatives, must not be

8-3 construed to violate any provision of law relating to solicitation or

8-4 advertising by practitioners of a healing art.

8-5 3. Any health maintenance organization authorized under this chapter

8-6 shall not be deemed to be practicing medicine and is exempt from the

8-7 provisions of chapter 630 of NRS.

8-8 4. The provisions of NRS 695C.110, 695C.170 to 695C.200, inclusive,

8-9 [and] sections 19 and 20 of [this act,] Senate Bill No. 2 of this session,

8-10 section 11.3 of this act and NRS695C.250 and 695C.265 do not apply to

8-11 a health maintenance organization that provides health care services

8-12 through managed care to recipients of Medicaid under the state plan for

8-13 Medicaid or insurance pursuant to the children’s health insurance program

8-14 pursuant to a contract with the division of health care financing and policy

8-15 of the department of human resources. This subsection does not exempt a

8-16 health maintenance organization from any provision of this chapter for

8-17 services provided pursuant to any other contract.

8-18 5. The provisions of NRS 695C.1694 and 695C.1695 apply to a health

8-19 maintenance organization that provides health care services through

8-20 managed care to recipients of Medicaid under the state plan for Medicaid.

8-21 Sec. 13. NRS 695C.055 is hereby amended to read as follows:

8-22 695C.055 1. The provisions of NRS 449.465, 679B.158, subsections

8-23 2, 4, 18, 19 and 32 of NRS 680B.010, NRS 680B.025 to 680B.060,

8-24 inclusive, [and 695G.010 to 695G.260, inclusive,] chapter 695G of NRS

8-25 and section 16 of this act, apply to a health maintenance organization.

8-26 2. For the purposes of subsection 1, unless the context requires that a

8-27 provision apply only to insurers, any reference in those sections to

8-28 “insurer” must be replaced by “health maintenance organization.”

8-29 Sec. 14. NRS 695C.125 is hereby amended to read as follows:

8-30 695C.125 A health maintenance organization [may] shall not charge a

8-31 provider of health care a fee to include the name of the provider on a list

8-32 of providers of health care given by the health maintenance organization to

8-33 its enrollees. [The amount of the fee must be reasonable and must not

8-34 exceed an amount that is directly related to the administrative costs of the

8-35 health maintenance organization to include the provider on the list.]

8-36 Sec. 15. NRS 695C.185 is hereby amended to read as follows:

8-37 695C.185 1. Except as otherwise provided in subsection 2, a health

8-38 maintenance organization shall approve or deny a claim relating to a

8-39 health care plan within 30 days after the health maintenance organization

8-40 receives the claim. If the claim is approved, the health maintenance

8-41 organization shall pay the claim within 30 days after it is approved. [If]

8-42 Except as otherwise provided in this section, if the approved claim is not

8-43 paid within that period, the health maintenance organization shall pay

8-44 interest on the claim at [the] a rate of interest [established pursuant to NRS

8-45 99.040 unless a different rate of interest is established pursuant to an

8-46 express written contract between the health maintenance organization and

8-47 the provider of health care.] equal to the prime rate at the largest bank in

8-48 Nevada, as ascertained by the commissioner of financial institutions, on

8-49 January 1 or July 1, as the case may be, immediately preceding the date

8-50 on which the payment was due, plus 6 percent. The interest must be

8-51 calculated from

9-1 30 days after the date on which the claim is approved until the date on

9-2 which the claim is paid.

9-3 2. If the health maintenance organization requires additional

9-4 information to determine whether to approve or deny the claim, it shall

9-5 notify the claimant of its request for the additional information within 20

9-6 days after it receives the claim. The health maintenance organization shall

9-7 notify the provider of health care services of all the specific reasons for the

9-8 delay in approving or denying the claim. The health maintenance

9-9 organization shall approve or deny the claim within 30 days after receiving

9-10 the additional information. If the claim is approved, the health

9-11 maintenance organization shall pay the claim within 30 days after it

9-12 receives the additional information. If the approved claim is not paid

9-13 within that period, the health maintenance organization shall pay interest

9-14 on the claim in the manner prescribed in subsection 1.

9-15 3. A health maintenance organization shall not request a claimant to

9-16 resubmit information that the claimant has already provided to the health

9-17 maintenance organization, unless the health maintenance organization

9-18 provides a legitimate reason for the request and the purpose of the request

9-19 is not to delay the payment of the claim, harass the claimant or discourage

9-20 the filing of claims.

9-21 4. A health maintenance organization shall not pay only part of a claim

9-22 that has been approved and is fully payable.

9-23 5. A court shall award costs and reasonable attorney’s fees to the

9-24 prevailing party in an action brought pursuant to this section.

9-25 6. The payment of interest provided for in this section for the late

9-26 payment of an approved claim may be waived only if the payment was

9-27 delayed because of an act of God or another cause beyond the control of

9-28 the health maintenance organization.

9-29 7. The commissioner may require a health maintenance organization

9-30 to provide evidence which demonstrates that the health maintenance

9-31 organization has substantially complied with the requirements set forth

9-32 in this section, including, without limitation, payment within 30 days of

9-33 at least 95 percent of approved claims or at least 90 percent of the total

9-34 dollar amount for approved claims. If the commissioner determines that

9-35 a health maintenance organization is not in substantial compliance with

9-36 the requirements set forth in this section, the commissioner may require

9-37 the health maintenance organization to pay an administrative fine in an

9-38 amount to be determined by the commissioner.

9-39 Sec. 16. Chapter 695G of NRS is hereby amended by adding thereto a

9-40 new section to read as follows:

9-41 A managed care organization that establishes a panel of providers of

9-42 health care for the purpose of offering health care services pursuant to

9-43 chapter 689A, 689B, 689C, 695A, 695B or 695C of NRS shall not charge

9-44 a provider of health care a fee to include the name of the provider on the

9-45 panel of providers of health care.

9-46 Sec. 17. Chapter 616C of NRS is hereby amended by adding thereto

9-47 the provisions set forth as sections 18 and 19 of this act.

9-48 Sec. 18. 1. Except as otherwise provided in this section, an insurer

9-49 shall approve or deny a bill for accident benefits received from a

9-50 provider of health care within 30 calendar days after the insurer receives

9-51 the bill.

10-1 If the bill for accident benefits is approved, the insurer shall pay the bill

10-2 within 30 calendar days after it is approved. Except as otherwise provided

10-3 in this section, if the approved bill for accident benefits is not paid within

10-4 that period, the insurer shall pay interest to the provider of health care at

10-5 a rate of interest equal to the prime rate at the largest bank in Nevada,

10-6 as ascertained by the commissioner of financial institutions, on January

10-7 1 or July 1, as the case may be, immediately preceding the date on which

10-8 the payment was due, plus 6 percent. The interest must be calculated

10-9 from 30 calendar days after the date on which the bill is approved until

10-10 the date on which the bill is paid.

10-11 2. If an insurer needs additional information to determine whether to

10-12 approve or deny a bill for accident benefits received from a provider of

10-13 health care, he shall notify the provider of health care of his request for

10-14 the additional information within 20 calendar days after he receives the

10-15 bill. The insurer shall notify the provider of health care of all the

10-16 specific reasons for the delay in approving or denying the bill for

10-17 accident benefits. Upon the receipt of such a request, the provider of

10-18 health care shall furnish the additional information to the insurer within

10-19 20 calendar days after receiving the request. If the provider of health

10-20 care fails to furnish the additional information within that period, the

10-21 provider of health care is not entitled to the payment of interest to which

10-22 he would otherwise be entitled for the late payment of the bill for

10-23 accident benefits. The insurer shall approve or deny the bill for accident

10-24 benefits within 20 calendar days after he receives the additional

10-25 information. If the bill for accident benefits is approved, the insurer

10-26 shall pay the bill within 20 calendar days after he receives the additional

10-27 information. Except as otherwise provided in this subsection, if the

10-28 approved bill for accident benefits is not paid within that period, the

10-29 insurer shall pay interest to the provider of health care at the rate set

10-30 forth in subsection 1. The interest must be calculated from 20 calendar

10-31 days after the date on which the insurer receives the additional

10-32 information until the date on which the bill is paid.

10-33 3. An insurer shall not request a provider of health care to resubmit

10-34 information that the provider of health care has previously provided to

10-35 the insurer, unless the insurer provides a legitimate reason for the

10-36 request and the purpose of the request is not to delay the payment of the

10-37 accident benefits, harass the provider of health care or discourage the

10-38 filing of claims.

10-39 4. An insurer shall not pay only a portion of a bill for accident

10-40 benefits that has been approved and is fully payable.

10-41 5. The administrator may require an insurer to provide evidence

10-42 which demonstrates that the insurer has substantially complied with the

10-43 requirements of this section, including, without limitation, payment

10-44 within the time required of at least 95 percent of approved accident

10-45 benefits or at least 90 percent of the total dollar amount of approved

10-46 accident benefits. If the administrator determines that an insurer is not

10-47 in substantial compliance with the requirements of this section, the

10-48 administrator may require the insurer to pay an administrative fine in

10-49 an amount to be determined by the administrator.

11-1 6. The payment of interest provided for in this section for the late

11-2 payment of an approved claim may be waived only if the payment was

11-3 delayed because of an act of God or another cause beyond the control of

11-4 the insurer.

11-5 7. Payments made by an insurer pursuant to this section are not an

11-6 admission of liability for the accident benefits or any portion of the

11-7 accident benefits.

11-8 Sec. 19. 1. If an insurer, organization for managed care or

11-9 employer who provides accident benefits for injured employees pursuant

11-10 to NRS 616C.265 denies payment for some or all of the services itemized

11-11 on a statement submitted by a provider of health care on the sole basis

11-12 that those services were not related to the employee’s industrial injury or

11-13 occupational disease, the insurer, organization for managed care or

11-14 employer shall, at the same time that it sends notification to the provider

11-15 of health care of the denial, send a copy of the statement to the injured

11-16 employee and notify the injured employee that it has denied payment.

11-17 The notification sent to the injured employee must:

11-18 (a) State the relevant amount requested as payment in the statement,

11-19 that the reason for denying payment is that the services were not related

11-20 to the industrial injury or occupational disease and that, pursuant to

11-21 subsection 2, the injured employee will be responsible for payment of the

11-22 relevant amount if he does not, in a timely manner, appeal the denial

11-23 pursuant to NRS 616C.305 and 616C.315 to 616C.385, inclusive, or

11-24 appeals but is not successful.

11-25 (b) Include an explanation of the injured employee’s right to request a

11-26 hearing to appeal the denialGreen numbers along left margin indicate location on the printed bill (e.g., 5-15 indicates page 5, line 15). pursuant to NRS 616C.305 and 616C.315 to

11-27 616C.385, inclusive, and a suitable form for requesting a hearing to

11-28 appeal the denial.

11-29 2. An injured employee who does not, in a timely manner, appeal the

11-30 denial of payment for the services rendered or who appeals the denial

11-31 but is not successful is responsible for payment of the relevant charges

11-32 on the itemized statement.

11-33 3. To succeed on appeal, the injured employee must show that the:

11-34 (a) Services provided were related to the employee’s industrial injury

11-35 or occupational disease; or

11-36 (b) Insurer, organization for managed care or employer who provides

11-37 accident benefits for injured employees pursuant to NRS 616C.265 gave

11-38 prior authorization for the services rendered and did not withdraw that

11-39 prior authorization before the services of the provider of health care

11-40 were rendered.

11-41 Sec. 20. NRS 616C.065 is hereby amended to read as follows:

11-42 616C.065 1. [Within] Except as otherwise provided in section 18 of

11-43 this act, within 30 days after the insurer has been notified of an industrial

11-44 accident, every insurer shall:

11-45 (a) Commence payment of a claim for compensation; or

11-46 (b) Deny the claim and notify the claimant and administrator that the

11-47 claim has been denied.

11-48 Payments made by an insurer pursuant to this section are not an admission

11-49 of liability for the claim or any portion of the claim.

12-1 2. [If] Except as otherwise provided in this subsection, if an insurer

12-2 unreasonably delays or refuses to pay the claim within 30 days after the

12-3 insurer has been notified of an industrial accident, the insurer shall pay

12-4 upon order of the administrator an additional amount equal to three times

12-5 the amount specified in the order as refused or unreasonably delayed. This

12-6 payment is for the benefit of the claimant and must be paid to him with the

12-7 compensation assessed pursuant to chapters 616A to 617, inclusive, of

12-8 NRS. The provisions of this section do not apply to the payment of a bill

12-9 for accident benefits that is governed by the provisions of section 18 of

12-10 this act.

12-11 Sec. 21. NRS 616C.135 is hereby amended to read as follows:

12-12 616C.135 1. A provider of health care who accepts a patient as a

12-13 referral for the treatment of an industrial injury or an occupational disease

12-14 may not charge the patient for any treatment related to the industrial injury

12-15 or occupational disease, but must charge the insurer. The provider of

12-16 health care may charge the patient for any [other unrelated services which

12-17 are requested in writing by the patient.] services that are not related to the

12-18 employee’s industrial injury or occupational disease.

12-19 2. The insurer is liable for the charges for approved services related to

12-20 the industrial injury or occupational disease if the charges do not exceed:

12-21 (a) The fees established in accordance with NRS 616C.260 or the usual

12-22 fee charged by that person or institution, whichever is less; and

12-23 (b) The charges provided for by the contract between the provider of

12-24 health care and the insurer or the contract between the provider of health

12-25 care and the organization for managed care.

12-26 3. If a provider of health care, an organization for managed care, an

12-27 insurer or an employer violates the provisions of this section, the

12-28 administrator shall impose an administrative fine of not more than $250

12-29 for each violation.

12-30 Sec. 22. NRS 616C.220 is hereby amended to read as follows:

12-31 616C.220 1. The division shall designate one:

12-32 (a) Third-party administrator who has a valid certificate issued by the

12-33 commissioner pursuant to NRS 683A.085; or

12-34 (b) Insurer, other than a self-insured employer or association of self

12-35 -insured public or private employers,

12-36 to administer claims against the uninsured employers’ claim fund. The

12-37 designation must be made pursuant to reasonable competitive bidding

12-38 procedures established by the administrator.

12-39 2. [An] Except as otherwise provided in this subsection, an employee

12-40 may receive compensation from the uninsured employers’ claim fund if:

12-41 (a) He was hired in this state or he is regularly employed in this state;

12-42 (b) He suffers an accident or injury [in this state] which arises out of

12-43 and in the course of his employment [;] :

12-44 (1) In this state; or

12-45 (2) While on temporary assignment outside the state for a period of

12-46 not more than 12 months;

12-47 (c) He files a claim for compensation with the division; and

12-48 (d) He makes an irrevocable assignment to the division of a right to be

12-49 subrogated to the rights of the injured employee pursuant to

12-50 NRS 616C.215.

13-1 An employee who suffers an accident or injury while on temporary

13-2 assignment outside the state is not eligible to receive compensation from

13-3 the uninsured employers’ claim fund unless he has been denied

13-4 workers’ compensation in the state in which the accident or injury

13-5 occurred.

13-6 3. If the division receives a claim pursuant to subsection 2, the division

13-7 shall immediately notify the employer of the claim.

13-8 4. For the purposes of this section, the employer has the burden of

13-9 proving that he provided mandatory industrial insurance coverage for the

13-10 employee or that he was not required to maintain industrial insurance for

13-11 the employee.

13-12 5. Any employer who has failed to provide mandatory coverage

13-13 required by the provisions of chapters 616A to 616D, inclusive, of NRS is

13-14 liable for all payments made on his behalf, including any benefits,

13-15 administrative costs or attorney’s fees paid from the uninsured employers’

13-16 claim fund or incurred by the division.

13-17 6. The division:

13-18 (a) May recover from the employer the payments made by the division

13-19 that are described in subsection 5 and any accrued interest by bringing a

13-20 civil action in district court.

13-21 (b) In any civil action brought against the employer, is not required to

13-22 prove that negligent conduct by the employer was the cause of the

13-23 employee’s injury.

13-24 (c) May enter into a contract with any person to assist in the collection

13-25 of any liability of an uninsured employer.

13-26 (d) In lieu of a civil action, may enter into an agreement or settlement

13-27 regarding the collection of any liability of an uninsured employer.

13-28 7. The division shall:

13-29 (a) Determine whether the employer was insured within 30 days after

13-30 receiving notice of the claim from the employee.

13-31 (b) Assign the claim to the third-party administrator or insurer

13-32 designated pursuant to subsection 1 for administration and payment of

13-33 compensation.

13-34 Upon determining whether the claim is accepted or denied, the designated

13-35 third-party administrator or insurer shall notify the injured employee, the

13-36 named employer and the division of its determination.

13-37 8. Upon demonstration of the:

13-38 (a) Costs incurred by the designated third-party administrator or insurer

13-39 to administer the claim or pay compensation to the injured employee; or

13-40 (b) Amount that the designated third-party administrator or insurer will

13-41 pay for administrative expenses or compensation to the injured employee

13-42 and that such amounts are justified by the circumstances of the

13-43 claim,

13-44 the division shall authorize payment from the uninsured employers’ claim

13-45 fund.

13-46 9. Any party aggrieved by a determination regarding the

13-47 administration of an assigned claim or a determination made by the

13-48 division or by the designated third-party administrator or insurer regarding

13-49 any claim made pursuant to this section may appeal that determination

13-50 within 60 days after the determination is rendered to the hearings division

14-1 of the department of administration in the manner provided by NRS

14-2 616C.305 and 616C.315 to 616C.385, inclusive.

14-3 10. All insurers shall bear a proportionate amount of a claim made

14-4 pursuant to chapters 616A to 616D, inclusive, of NRS, and are entitled to

14-5 a proportionate amount of any collection made pursuant to this section as

14-6 an offset against future liabilities.

14-7 11. An uninsured employer is liable for the interest on any amount

14-8 paid on his claims from the uninsured employers’ claim fund. The interest

14-9 must be calculated at a rate equal to the prime rate at the largest bank in

14-10 Nevada, as ascertained by the commissioner of financial institutions, on

14-11 January 1 or July 1, as the case may be, immediately preceding the date of

14-12 the claim, plus 3 percent, compounded monthly, from the date the claim is

14-13 paid from the fund until payment is received by the division from the

14-14 employer.

14-15 12. Attorney’s fees recoverable by the division pursuant to this section

14-16 must be:

14-17 (a) If a private attorney is retained by the division, paid at the usual and

14-18 customary rate for that attorney.

14-19 (b) If the attorney is an employee of the division, paid at the rate

14-20 established by regulations adopted by the division.

14-21 Any money collected must be deposited to the uninsured employers’ claim

14-22 fund.

14-23 13. In addition to any other liabilities provided for in this section, the

14-24 administrator may impose an administrative fine of not more than $10,000

14-25 against an employer if the employer fails to provide mandatory coverage

14-26 required by the provisions of chapters 616A to 616D, inclusive, of NRS.

14-27 Sec. 23. NRS 617.401 is hereby amended to read as follows:

14-28 617.401 1. The division shall designate one:

14-29 (a) Third-party administrator who has a valid certificate issued by the

14-30 commissioner pursuant to NRS 683A.085; or

14-31 (b) Insurer, other than a self-insured employer or association of self

14-32 -insured public or private employers,

14-33 to administer claims against the uninsured employers’ claim fund. The

14-34 designation must be made pursuant to reasonable competitive bidding

14-35 procedures established by the administrator.

14-36 2. [An] Except as otherwise provided in this subsection, an employee

14-37 may receive compensation from the uninsured employers’ claim fund if:

14-38 (a) He was hired in this state or he is regularly employed in this state;

14-39 (b) He contracts an occupational disease [as a result of work performed

14-40 in this state;] that arose out of and in the course of employment:

14-41 (1) In this state; or

14-42 (2) While on temporary assignment outside the state for a period of

14-43 not more than 12 months;

14-44 (c) He files a claim for compensation with the division; and

14-45 (d) He makes an irrevocable assignment to the division of a right to be

14-46 subrogated to the rights of the employee pursuant to NRS 616C.215.

14-47 An employee who contracts an occupational disease that arose out of and

14-48 in the course of employment while on temporary assignment outside the

14-49 state is not entitled to receive compensation from the uninsured

15-1 employers’ claim fund unless he has been denied workers’ compensation

15-2 in the state in which the disease was contracted.

15-3 3. If the division receives a claim pursuant to subsection 2, the division

15-4 shall immediately notify the employer of the claim.

15-5 4. For the purposes of this section, the employer has the burden of

15-6 proving that he provided mandatory coverage for occupational diseases for

15-7 the employee or that he was not required to maintain industrial insurance

15-8 for the employee.

15-9 5. Any employer who has failed to provide mandatory coverage

15-10 required by the provisions of this chapter is liable for all payments made

15-11 on his behalf, including, but not limited to, any benefits, administrative

15-12 costs or attorney’s fees paid from the uninsured employers’ claim fund or

15-13 incurred by the division.

15-14 6. The division:

15-15 (a) May recover from the employer the payments made by the division

15-16 that are described in subsection 5 and any accrued interest by bringing a

15-17 civil action in district court.

15-18 (b) In any civil action brought against the employer, is not required to

15-19 prove that negligent conduct by the employer was the cause of the

15-20 occupational disease.

15-21 (c) May enter into a contract with any person to assist in the collection

15-22 of any liability of an uninsured employer.

15-23 (d) In lieu of a civil action, may enter into an agreement or settlement

15-24 regarding the collection of any liability of an uninsured employer.

15-25 7. The division shall:

15-26 (a) Determine whether the employer was insured within 30 days after

15-27 receiving the claim from the employee.

15-28 (b) Assign the claim to the third-party administrator or insurer

15-29 designated pursuant to subsection 1 for administration and payment of

15-30 compensation.

15-31 Upon determining whether the claim is accepted or denied, the designated

15-32 third-party administrator or insurer shall notify the injured employee, the

15-33 named employer and the division of its determination.

15-34 8. Upon demonstration of the:

15-35 (a) Costs incurred by the designated third-party administrator or insurer

15-36 to administer the claim or pay compensation to the injured employee; or

15-37 (b) Amount that the designated third-party administrator or insurer will

15-38 pay for administrative expenses or compensation to the injured employee

15-39 and that such amounts are justified by the circumstances of the

15-40 claim,

15-41 the division shall authorize payment from the uninsured employers’ claim

15-42 fund.

15-43 9. Any party aggrieved by a determination regarding the

15-44 administration of an assigned claim or a determination made by the

15-45 division or by the designated third-party administrator or insurer regarding

15-46 any claim made pursuant to this section may appeal that determination

15-47 within 60 days after the determination is rendered to the hearings division

15-48 of the department of administration in the manner provided by NRS

15-49 616C.305 and 616C.315 to 616C.385, inclusive.

16-1 10. All insurers shall bear a proportionate amount of a claim made

16-2 pursuant to this chapter, and are entitled to a proportionate amount of any

16-3 collection made pursuant to this section as an offset against future

16-4 liabilities.

16-5 11. An uninsured employer is liable for the interest on any amount

16-6 paid on his claims from the uninsured employers’ claim fund. The interest

16-7 must be calculated at a rate equal to the prime rate at the largest bank in

16-8 Nevada, as ascertained by the commissioner of financial institutions, on

16-9 January 1 or July 1, as the case may be, immediately preceding the date of

16-10 the claim, plus 3 percent, compounded monthly, from the date the claim is

16-11 paid from the fund until payment is received by the division from the

16-12 employer.

16-13 12. Attorney’s fees recoverable by the division pursuant to this section

16-14 must be:

16-15 (a) If a private attorney is retained by the division, paid at the usual and

16-16 customary rate for that attorney.

16-17 (b) If the attorney is an employee of the division, paid at the rate

16-18 established by regulations adopted by the division.

16-19 Any money collected must be deposited to the uninsured employers’ claim

16-20 fund.

16-21 13. In addition to any other liabilities provided for in this section, the

16-22 administrator may impose an administrative fine of not more than $10,000

16-23 against an employer if the employer fails to provide mandatory coverage

16-24 required by the provisions of this chapter.

16-25 Sec. 23.5. Section 10 of Assembly Bill No. 338 of this session is

16-26 hereby amended to read as follows:

16-27 Sec. 10. NRS 616C.135 is hereby amended to read as follows:

16-28 616C.135 1. A provider of health care who accepts a patient as

16-29 a referral for the treatment of an industrial injury or an occupational

16-30 disease may not charge the patient for any treatment related to the

16-31 industrial injury or occupational disease, but must charge the insurer.

16-32 The provider of health care may charge the patient for any services

16-33 that are not related to the employee’s industrial injury or occupational

16-34 disease.

16-35 2. The insurer is liable for the charges for approved services

16-36 related to the industrial injury or occupational disease if the charges

16-37 do not exceed:

16-38 (a) The fees established in accordance with NRS 616C.260 or the

16-39 usual fee charged by that person or institution, whichever is less; and

16-40 (b) The charges provided for by the contract between the provider

16-41 of health care and the insurer or the contract between the provider of

16-42 health care and the organization for managed care.

16-43 3. A provider of health care may accept payment from an

16-44 injured employee who is paying in protest pursuant to section 5 of

16-45 this act for treatment or other services that the injured employee

16-46 alleges are related to the industrial injury or occupational disease.

16-47 4. If a provider of health care, an organization for managed care,

16-48 an insurer or an employer violates the provisions of this section, the

16-49 administrator shall impose an administrative fine of not more than

16-50 $250 for each violation.

17-1 Sec. 24. If a different rate of interest has been established pursuant to

17-2 an express written contract between an administrator, insurer, carrier,

17-3 corporation or health maintenance organization and a provider of health

17-4 care, the amendatory provisions of sections 1.5, 3, 5, 7, 10, 11.3, 15 and 18

17-5 of this act, relating to the amount of interest that accrues if an approved

17-6 claim is not timely paid, apply only to contracts between the administrator,

17-7 insurer, carrier, corporation or health maintenance organization and the

17-8 provider of health care that are entered into or renewed on or after

17-9 October 1, 2001.

17-10 Sec. 25. 1. This section, sections 1 to 11.7, inclusive, and 13 to 24,

17-11 inclusive, of this act become effective on October 1, 2001.

17-12 2. Section 12 of this act becomes effective at 12:01 a.m. on October 1,

17-13 2001.

17-14 ²⁰~~~~~⁰¹