(REPRINTED WITH ADOPTED AMENDMENTS)

 

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

 

February 12, 2001

____________

 

Referred to Committee on Commerce and Labor

 

SUMMARY—Makes various changes to provisions relating to prompt payment of claims to providers of health care. (BDR 57‑132)

 

FISCAL NOTE:            Effect on Local Government: No.

                                    Effect on the State: No.

 

~

 

EXPLANATION – Matter in bolded italics is new; matter between brackets [omitted material] is material to be omitted.

 

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; 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, a

1-9  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 administrators.

1-14    2.  As used in this section:

1-15    (a) “Administrator” has the meaning ascribed to it in NRS 683A.025.

1-16    (b) “Health care plan” means a policy, contract, certificate or agreement

1-17  offered or issued by an insurer to provide, deliver, arrange for, pay for or

1-18  reimburse any of the costs of health care services.

 

2-1    Sec. 1.5.  NRS 683A.0879 is hereby amended to read as follows:

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

2-3  administrator shall approve or deny a claim relating to health insurance

2-4  coverage within 30 days after the administrator receives the claim. If the

2-5  claim is approved, the administrator shall pay the claim within 30 days

2-6  after it is approved. If the approved claim is not paid within that period, the

2-7  administrator shall pay interest on the claim at [the] a rate of interest

2-8  [established pursuant to NRS 99.040 unless a different rate of interest is

2-9  established pursuant to an express written contract between the

2-10  administrator and the provider of health care.] equal to the prime rate at

2-11  the largest bank in Nevada, as ascertained by the commissioner of

2-12  financial institutions, on January 1 or July 1, as the case may be,

2-13  immediately preceding the date on which the payment was due, plus 6

2-14  percent. The interest must be calculated from 30 days after the date on

2-15  which the claim is approved until the date on which the claim is paid.

2-16    2.  If the administrator requires additional information to determine

2-17  whether to approve or deny the claim, he shall notify the claimant of his

2-18  request for the additional information within 20 days after he receives the

2-19  claim. The administrator shall notify the provider of health care of all the

2-20  specific reasons for the delay in approving or denying the claim. The

2-21  administrator shall approve or deny the claim within 30 days after

2-22  receiving the additional information. If the claim is approved, the

2-23  administrator shall pay the claim within 30 days after he receives the

2-24  additional information. If the approved claim is not paid within that period,

2-25  the administrator shall pay interest on the claim in the manner prescribed in

2-26  subsection 1.

2-27    3.  An administrator shall not request a claimant to resubmit

2-28  information that the claimant has already provided to the administrator,

2-29  unless the administrator provides a legitimate reason for the request and the

2-30  purpose of the request is not to delay the payment of the claim, harass the

2-31  claimant or discourage the filing of claims.

2-32    4.  An administrator shall not pay only part of a claim that has been

2-33  approved and is fully payable.

2-34    5.  A court shall award costs and reasonable attorney’s fees to the

2-35  prevailing party in an action brought pursuant to this section.

2-36    6.  The payment of interest provided for in this section for the late

2-37  payment of an approved claim may not be waived.

2-38    7.  The commissioner may require an administrator to provide

2-39  evidence which demonstrates that the administrator has substantially

2-40  complied with the requirements set forth in this section, including,

2-41  without limitation, payment within 30 days of at least 95 percent of

2-42  approved claims or at least 90 percent of the total dollar amount for

2-43  approved claims. If the commissioner determines that an administrator is

2-44  not in substantial compliance with the requirements set forth in this

2-45  section, the commissioner may require the administrator to pay an

2-46  administrative fine in an amount to be determined by the commissioner.

2-47    Sec. 2.  NRS 689A.035 is hereby amended to read as follows:

2-48    689A.035  An insurer [may] shall not charge a provider of health care

2-49  a fee to include the name of the provider on a list of providers of health

3-1  care given by the insurer to its insureds. [The amount of the fee must be

3-2  reasonable and must not exceed an amount that is directly related to the

3-3  administrative costs of the insurer to include the provider on the list.]

3-4    Sec. 3.  NRS 689A.410 is hereby amended to read as follows:

3-5    689A.410  1.  Except as otherwise provided in subsection 2, an insurer

3-6  shall approve or deny a claim relating to a policy of health insurance within

3-7  30 days after the insurer receives the claim. If the claim is approved, the

3-8  insurer shall pay the claim within 30 days after it is approved. If the

3-9  approved claim is not paid within that period, the insurer shall pay interest

3-10  on the claim at [the] a rate of interest [established pursuant to NRS 99.040

3-11  unless a different rate of interest is established pursuant to an express

3-12  written contract between the insurer and the provider of health care.] equal

3-13  to the prime rate at the largest bank in Nevada, as ascertained by the

3-14  commissioner of financial institutions, on January 1 or July 1, as the

3-15  case may be, immediately preceding the date on which the payment was

3-16  due, plus 6 percent. The interest must be calculated from 30 days after the

3-17  date on which the claim is approved until the date on which the claim is

3-18  paid.

3-19    2.  If the insurer requires additional information to determine whether

3-20  to approve or deny the claim, it shall notify the claimant of its request for

3-21  the additional information within 20 days after it receives the claim. The

3-22  insurer shall notify the provider of health care of all the specific reasons for

3-23  the delay in approving or denying the claim. The insurer shall approve or

3-24  deny the claim within 30 days after receiving the additional information. If

3-25  the claim is approved, the insurer shall pay the claim within 30 days after it

3-26  receives the additional information. If the approved claim is not paid within

3-27  that period, the insurer shall pay interest on the claim in the manner

3-28  prescribed in subsection 1.

3-29    3.  An insurer shall not request a claimant to resubmit information that

3-30  the claimant has already provided to the insurer, unless the insurer provides

3-31  a legitimate reason for the request and the purpose of the request is not to

3-32  delay the payment of the claim, harass the claimant or discourage the filing

3-33  of claims.

3-34    4.  An insurer shall not pay only part of a claim that has been approved

3-35  and is fully payable.

3-36    5.  A court shall award costs and reasonable attorney’s fees to the

3-37  prevailing party in an action brought pursuant to this section.

3-38    6.  The payment of interest provided for in this section for the late

3-39  payment of an approved claim may not be waived.

3-40    7.  The commissioner may require an insurer to provide evidence

3-41  which demonstrates that the insurer has substantially complied with the

3-42  requirements set forth in this section, including, without limitation,

3-43  payment within 30 days of at least 95 percent of approved claims or at

3-44  least 90 percent of the total dollar amount for approved claims. If the

3-45  commissioner determines that an insurer is not in substantial compliance

3-46  with the requirements set forth in this section, the commissioner may

3-47  require the insurer to pay an administrative fine in an amount to be

3-48  determined by the commissioner.

 

 

4-1    Sec. 4.  NRS 689B.015 is hereby amended to read as follows:

4-2    689B.015  An insurer that issues a policy of group health insurance

4-3  [may] shall not charge a provider of health care a fee to include the name

4-4  of the provider on a list of providers of health care given by the insurer to

4-5  its insureds. [The amount of the fee must be reasonable and must not

4-6  exceed an amount that is directly related to the administrative costs of the

4-7  insurer to include the provider on the list.]

4-8    Sec. 5.  NRS 689B.255 is hereby amended to read as follows:

4-9    689B.255  1.  Except as otherwise provided in subsection 2, an insurer

4-10  shall approve or deny a claim relating to a policy of group health insurance

4-11  or blanket insurance within 30 days after the insurer receives the claim. If

4-12  the claim is approved, the insurer shall pay the claim within 30 days after it

4-13  is approved. If the approved claim is not paid within that period, the insurer

4-14  shall pay interest on the claim at [the] a rate of interest [established

4-15  pursuant to NRS 99.040 unless a different rate of interest is established

4-16  pursuant to an express written contract between the insurer and the

4-17  provider of health care.] equal to the prime rate at the largest bank in

4-18  Nevada, as ascertained by the commissioner of financial institutions, on

4-19  January 1 or July 1, as the case may be, immediately preceding the date

4-20  on which the payment was due, plus 6 percent. The interest must be

4-21  calculated from 30 days after the date on which the claim is approved until

4-22  the date on which the claim is paid.

4-23    2.  If the insurer requires additional information to determine whether

4-24  to approve or deny the claim, it shall notify the claimant of its request for

4-25  the additional information within 20 days after it receives the claim. The

4-26  insurer shall notify the provider of health care of all the specific reasons for

4-27  the delay in approving or denying the claim. The insurer shall approve or

4-28  deny the claim within 30 days after receiving the additional information. If

4-29  the claim is approved, the insurer shall pay the claim within 30 days after it

4-30  receives the additional information. If the approved claim is not paid within

4-31  that period, the insurer shall pay interest on the claim in the manner

4-32  prescribed in subsection 1.

4-33    3.  An insurer shall not request a claimant to resubmit information that

4-34  the claimant has already provided to the insurer, unless the insurer provides

4-35  a legitimate reason for the request and the purpose of the request [in] is not

4-36  to delay the payment of the claim, harass the claimant or discourage the

4-37  filing of claims.

4-38    4.  An insurer shall not pay only part of a claim that has been approved

4-39  and is fully payable.

4-40    5.  A court shall award costs and reasonable attorney’s fees to the

4-41  prevailing party in an action brought pursuant to this section.

4-42    6.  The payment of interest provided for in this section for the late

4-43  payment of an approved claim may not be waived.

4-44    7.  The commissioner may require an insurer to provide evidence

4-45  which demonstrates that the insurer has substantially complied with the

4-46  requirements set forth in this section, including, without limitation,

4-47  payment within 30 days of at least 95 percent of approved claims or at

4-48  least 90 percent of the total dollar amount for approved claims. If the

5-1  commissioner determines that an insurer is not in substantial compliance

5-2  with the requirements set forth in this section, the commissioner may

5-3  require the insurer to pay an administrative fine in an amount to be

5-4  determined by the commissioner.

5-5    Sec. 6.  NRS 689C.435 is hereby amended to read as follows:

5-6    689C.435  A carrier serving small employers and a carrier that offers a

5-7  contract to a voluntary purchasing group [may] shall not charge a provider

5-8  of health care a fee to include the name of the provider on a list of

5-9  providers of health care given by the carrier to its insureds. [The amount of

5-10  the fee must be reasonable and must not exceed an amount that is directly

5-11  related to the administrative costs of the carrier to include the provider on

5-12  the list.]

5-13    Sec. 7.  NRS 689C.485 is hereby amended to read as follows:

5-14    689C.485  1.  Except as otherwise provided in subsection 2, a carrier

5-15  serving small employers and a carrier that offers a contract to a voluntary

5-16  purchasing group shall approve or deny a claim relating to a policy of

5-17  health insurance within 30 days after the carrier receives the claim. If the

5-18  claim is approved, the carrier shall pay the claim within 30 days after it is

5-19  approved. If the approved claim is not paid within that period, the carrier

5-20  shall pay interest on the claim at [the] a rate of interest [established

5-21  pursuant to NRS 99.040 unless a different rate of interest is established

5-22  pursuant to an express written contract between the carrier and the provider

5-23  of health care.] equal to the prime rate at the largest bank in Nevada, as

5-24  ascertained by the commissioner of financial institutions, on January 1

5-25  or July 1, as the case may be, immediately preceding the date on which

5-26  the payment was due, plus 6 percent. The interest must be calculated from

5-27  30 days after the date on which the claim is approved until the date on

5-28  which the claim is paid.

5-29    2.  If the carrier requires additional information to determine whether to

5-30  approve or deny the claim, it shall notify the claimant of its request for the

5-31  additional information within 20 days after it receives the claim. The

5-32  carrier shall notify the provider of health care of all the specific reasons for

5-33  the delay in approving or denying the claim. The carrier shall approve or

5-34  deny the claim within 30 days after receiving the additional information. If

5-35  the claim is approved, the carrier shall pay the claim within 30 days after it

5-36  receives the additional information. If the approved claim is not paid within

5-37  that period, the carrier shall pay interest on the claim in the manner

5-38  prescribed in subsection 1.

5-39    3.  A carrier shall not request a claimant to resubmit information that

5-40  the claimant has already provided to the carrier, unless the carrier provides

5-41  a legitimate reason for the request and the purpose of the request is not to

5-42  delay the payment of the claim, harass the claimant or discourage the filing

5-43  of claims.

5-44    4.  A carrier shall not pay only part of a claim that has been approved

5-45  and is fully payable.

5-46    5.  A court shall award costs and reasonable attorney’s fees to the

5-47  prevailing party in an action brought pursuant to this section.

5-48    6.  The payment of interest provided for in this section for the late

5-49  payment of an approved claim may not be waived.

6-1    7.  The commissioner may require a carrier to provide evidence

6-2  which demonstrates that the carrier has substantially complied with the

6-3  requirements set forth in this section, including, without limitation,

6-4  payment within 30 days of at least 95 percent of approved claims or at

6-5  least 90 percent of the total dollar amount for approved claims. If the

6-6  commissioner determines that a carrier is not in substantial compliance

6-7  with the requirements set forth in this section, the commissioner may

6-8  require the carrier to pay an administrative fine in an amount to be

6-9  determined by the commissioner.

6-10    Sec. 8.  NRS 695A.095 is hereby amended to read as follows:

6-11    695A.095  A society [may] shall not charge a provider of health care a

6-12  fee to include the name of the provider on a list of providers of health care

6-13  given by the society to its insureds. [The amount of the fee must be

6-14  reasonable and must not exceed an amount that is directly related to the

6-15  administrative costs of the society to include the provider on the list.]

6-16    Sec. 9.  NRS 695B.035 is hereby amended to read as follows:

6-17    695B.035  A corporation subject to the provisions of this chapter [may]

6-18  shall not charge a provider of health care a fee to include the name of the

6-19  provider on a list of providers of health care given by the corporation to its

6-20  insureds. [The amount of the fee must be reasonable and must not exceed

6-21  an amount that is directly related to the administrative costs of the

6-22  corporation to include the provider on the list.]

6-23    Sec. 10.  NRS 695B.2505 is hereby amended to read as follows:

6-24    695B.2505  1.  Except as otherwise provided in subsection 2, a

6-25  corporation subject to the provisions of this chapter shall approve or deny a

6-26  claim relating to a contract for dental, hospital or medical services within

6-27  30 days after the corporation receives the claim. If the claim is approved,

6-28  the corporation shall pay the claim within 30 days after it is approved. If

6-29  the approved claim is not paid within that period, the corporation shall pay

6-30  interest on the claim at [the] a rate of interest [established pursuant to NRS

6-31  99.040 unless a different rate of interest is established pursuant to an

6-32  express written contract between the corporation and the provider of health

6-33  care.] equal to the prime rate at the largest bank in Nevada, as

6-34  ascertained by the commissioner of financial institutions, on January 1

6-35  or July 1, as the case may be, immediately preceding the date on which

6-36  the payment was due, plus 6 percent. The interest must be calculated from

6-37  30 days after the date on which the claim is approved until the date on

6-38  which the claim is paid.

6-39    2.  If the corporation requires additional information to determine

6-40  whether to approve or deny the claim, it shall notify the claimant of its

6-41  request for the additional information within 20 days after it receives the

6-42  claim. The corporation shall notify the provider of dental, hospital or

6-43  medical services of all the specific reasons for the delay in approving or

6-44  denying the claim. The corporation shall approve or deny the claim within

6-45  30 days after receiving the additional information. If the claim is approved,

6-46  the corporation shall pay the claim within 30 days after it receives the

6-47  additional information. If the approved claim is not paid within that period,

6-48  the corporation shall pay interest on the claim in the manner prescribed in

6-49  subsection 1.

7-1    3.  A corporation shall not request a claimant to resubmit information

7-2  that the claimant has already provided to the corporation, unless the

7-3  corporation provides a legitimate reason for the request and the purpose of

7-4  the request is not to delay the payment of the claim, harass the claimant or

7-5  discourage the filing of claims.

7-6    4.  A corporation shall not pay only part of a claim that has been

7-7  approved and is fully payable.

7-8    5.  A court shall award costs and reasonable attorney’s fees to the

7-9  prevailing party in an action brought pursuant to this section.

7-10    6.  The payment of interest provided for in this section for the late

7-11  payment of an approved claim may not be waived.

7-12    7.  The commissioner may require a corporation to provide evidence

7-13  which demonstrates that the corporation has substantially complied with

7-14  the requirements set forth in this section, including, without limitation,

7-15  payment within 30 days of at least 95 percent of approved claims or at

7-16  least 90 percent of the total dollar amount for approved claims. If the

7-17  commissioner determines that a corporation is not in substantial

7-18  compliance with the requirements set forth in this section, the

7-19  commissioner may require the corporation to pay an administrative fine

7-20  in an amount to be determined by the commissioner.

7-21    Sec. 11.  Chapter 695C of NRS is hereby amended by adding thereto a

7-22  new section to read as follows:

7-23    1.  A health maintenance organization shall not:

7-24    (a) Enter into any contract or agreement, or make any other

7-25  arrangements, with a provider for the provision of health care; or

7-26    (b) Employ a provider pursuant to a contract, an agreement or any

7-27  other arrangement to provide health care,

7-28  unless the contract, agreement or other arrangement specifically

7-29  provides that the health maintenance organization and provider agree to

7-30  the schedule for the payment of claims set forth in NRS 695C.185.

7-31    2.  Any contract, agreement or other arrangement between a health

7-32  maintenance organization and a provider that is entered into or renewed

7-33  on or after the effective date of this act that does not specifically include

7-34  a provision concerning the schedule for the payment of claims as

7-35  required by subsection 1 shall be deemed to conform with the

7-36  requirements of subsection 1 by operation of law.

7-37    Sec. 12.  NRS 695C.050 is hereby amended to read as follows:

7-38    695C.050  1.  Except as otherwise provided in this chapter or in

7-39  specific provisions of this Title, the provisions of this Title are not

7-40  applicable to any health maintenance organization granted a certificate of

7-41  authority under this chapter. This provision does not apply to an insurer

7-42  licensed and regulated pursuant to this Title except with respect to its

7-43  activities as a health maintenance organization authorized and regulated

7-44  pursuant to this chapter.

7-45    2.  Solicitation of enrollees by a health maintenance organization

7-46  granted a certificate of authority, or its representatives, must not be

7-47  construed to violate any provision of law relating to solicitation or

7-48  advertising by practitioners of a healing art.

8-1    3.  Any health maintenance organization authorized under this chapter

8-2  shall not be deemed to be practicing medicine and is exempt from the

8-3  provisions of chapter 630 of NRS.

8-4    4.  The provisions of NRS 695C.110, 695C.170 to 695C.180, inclusive,

8-5  695C.190 to 695C.200, inclusive, 695C.250 and 695C.265 do not apply to

8-6  a health maintenance organization that provides health care services

8-7  through managed care to recipients of Medicaid under the state plan for

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

8-9  pursuant to a contract with the division of health care financing and policy

8-10  of the department of human resources. This subsection does not exempt a

8-11  health maintenance organization from any provision of this chapter for

8-12  services provided pursuant to any other contract.

8-13    5.  The provisions of NRS 695C.1694 and 695C.1695 apply to a health

8-14  maintenance organization that provides health care services through

8-15  managed care to recipients of Medicaid under the state plan for Medicaid.

8-16    Sec. 13.  NRS 695C.055 is hereby amended to read as follows:

8-17    695C.055  1.  The provisions of NRS 449.465, 679B.158, subsections

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

8-19  inclusive, [and 695G.010 to 695G.260, inclusive,] chapter 695G of NRS

8-20  and section 16 of this act, apply to a health maintenance organization.

8-21    2.  For the purposes of subsection 1, unless the context requires that a

8-22  provision apply only to insurers, any reference in those sections to

8-23  “insurer” must be replaced by “health maintenance organization.”

8-24    Sec. 14.  NRS 695C.125 is hereby amended to read as follows:

8-25    695C.125  A health maintenance organization [may] shall not charge a

8-26  provider of health care a fee to include the name of the provider on a list of

8-27  providers of health care given by the health maintenance organization to its

8-28  enrollees. [The amount of the fee must be reasonable and must not exceed

8-29  an amount that is directly related to the administrative costs of the health

8-30  maintenance organization to include the provider on the list.]

8-31    Sec. 15.  NRS 695C.185 is hereby amended to read as follows:

8-32    695C.185  1.  Except as otherwise provided in subsection 2, a health

8-33  maintenance organization shall approve or deny a claim relating to a health

8-34  care plan within 30 days after the health maintenance organization receives

8-35  the claim. If the claim is approved, the health maintenance organization

8-36  shall pay the claim within 30 days after it is approved. If the approved

8-37  claim is not paid within that period, the health maintenance organization

8-38  shall pay interest on the claim at [the] a rate of interest [established

8-39  pursuant to NRS 99.040 unless a different rate of interest is established

8-40  pursuant to an express written contract between the health maintenance

8-41  organization and the provider of health care.] equal to the prime rate at the

8-42  largest bank in Nevada, as ascertained by the commissioner of financial

8-43  institutions, on January 1 or July 1, as the case may be, immediately

8-44  preceding the date on which the payment was due, plus 6 percent. The

8-45  interest must be calculated from 30 days after the date on which the claim

8-46  is approved until the date on which the claim is paid.

8-47    2.  If the health maintenance organization requires additional

8-48  information to determine whether to approve or deny the claim, it shall

8-49  notify the claimant of its request for the additional information within 20

9-1  days after it receives the claim. The health maintenance organization shall

9-2  notify the provider of health care services of all the specific reasons for the

9-3  delay in approving or denying the claim. The health maintenance

9-4  organization shall approve or deny the claim within 30 days after receiving

9-5  the additional information. If the claim is approved, the health maintenance

9-6  organization shall pay the claim within 30 days after it receives the

9-7  additional information. If the approved claim is not paid within that period,

9-8  the health maintenance organization shall pay interest on the claim in the

9-9  manner prescribed in subsection 1.

9-10    3.  A health maintenance organization shall not request a claimant to

9-11  resubmit information that the claimant has already provided to the health

9-12  maintenance organization, unless the health maintenance organization

9-13  provides a legitimate reason for the request and the purpose of the request

9-14  is not to delay the payment of the claim, harass the claimant or discourage

9-15  the filing of claims.

9-16    4.  A health maintenance organization shall not pay only part of a claim

9-17  that has been approved and is fully payable.

9-18    5.  A court shall award costs and reasonable attorney’s fees to the

9-19  prevailing party in an action brought pursuant to this section.

9-20    6.  The payment of interest provided for in this section for the late

9-21  payment of an approved claim may not be waived.

9-22    7.  The commissioner may require a health maintenance organization

9-23  to provide evidence which demonstrates that the health maintenance

9-24  organization has substantially complied with the requirements set forth

9-25  in this section, including, without limitation, payment within 30 days of

9-26  at least 95 percent of approved claims or at least 90 percent of the total

9-27  dollar amount for approved claims. If the commissioner determines that

9-28  a health maintenance organization is not in substantial compliance with

9-29  the requirements set forth in this section, the commissioner may require

9-30  the health maintenance organization to pay an administrative fine in an

9-31  amount to be determined by the commissioner.

9-32    Sec. 16.  Chapter 695G of NRS is hereby amended by adding thereto a

9-33  new section to read as follows:

9-34    A managed care organization that establishes a panel of providers of

9-35  health care for the purpose of offering health care services pursuant to

9-36  chapter 689A, 689B, 689C, 695A, 695B or 695C of NRS shall not charge

9-37  a provider of health care a fee to include the name of the provider on the

9-38  panel of providers of health care.

9-39    Sec. 17.  Chapter 616C of NRS is hereby amended by adding thereto

9-40  the provisions set forth as sections 18 and 19 of this act.

9-41    Sec. 18. 1.  Except as otherwise provided in this section, an insurer

9-42  shall approve or deny a bill for accident benefits received from a provider

9-43  of health care within 30 calendar days after the insurer receives the bill.

9-44  If the bill for accident benefits is approved, the insurer shall pay the bill

9-45  within 30 calendar days after it is approved. If the approved bill for

9-46  accident benefits is not paid within that period, the insurer shall pay

9-47  interest to the provider of health care at a rate of interest equal to the

9-48  prime rate at the largest bank in Nevada, as ascertained by the

9-49  commissioner of financial institutions, on January 1 or July 1, as the

10-1  case may be, immediately preceding the date on which the payment was

10-2  due, plus 6 percent. The interest must be calculated from 30 calendar

10-3  days after the date on which the bill is approved until the date on which

10-4  the bill is paid.

10-5    2.  If an insurer needs additional information to determine whether to

10-6  approve or deny a bill for accident benefits received from a provider of

10-7  health care, he shall notify the provider of health care of his request for

10-8  the additional information within 20 calendar days after he receives the

10-9  bill. The insurer shall notify the provider of health care of all the specific

10-10  reasons for the delay in approving or denying the bill for accident

10-11  benefits. Upon the receipt of such a request, the provider of health care

10-12  shall furnish the additional information to the insurer within 20 calendar

10-13  days after receiving the request. If the provider of health care fails to

10-14  furnish the additional information within that period, the provider of

10-15  health care is not entitled to the payment of interest to which he would

10-16  otherwise be entitled for the late payment of the bill for accident benefits.

10-17  The insurer shall approve or deny the bill for accident benefits within 20

10-18  calendar days after he receives the additional information. If the bill for

10-19  accident benefits is approved, the insurer shall pay the bill within 20

10-20  calendar days after he receives the additional information. Except as

10-21  otherwise provided in this subsection, if the approved bill for accident

10-22  benefits is not paid within that period, the insurer shall pay interest to the

10-23  provider of health care at the rate set forth in subsection 1. The interest

10-24  must be calculated from 20 calendar days after the date on which the

10-25  insurer receives the additional information until the date on which the

10-26  bill is paid.

10-27  3.  An insurer shall not request a provider of health care to resubmit

10-28  information that the provider of health care has previously provided to

10-29  the insurer, unless the insurer provides a legitimate reason for the

10-30  request and the purpose of the request is not to delay the payment of the

10-31  accident benefits, harass the provider of health care or discourage the

10-32  filing of claims.

10-33  4.  An insurer shall not pay only a portion of a bill for accident

10-34  benefits that has been approved and is fully payable.

10-35  5.  The administrator may require an insurer to provide evidence

10-36  which demonstrates that the insurer has substantially complied with the

10-37  requirements of this section, including, without limitation, payment

10-38  within the time required of at least 95 percent of approved accident

10-39  benefits or at least 90 percent of the total dollar amount of approved

10-40  accident benefits. If the administrator determines that an insurer is not

10-41  in substantial compliance with the requirements of this section, the

10-42  administrator may require the insurer to pay an administrative fine in an

10-43  amount to be determined by the administrator.

10-44  6.  The payment of interest provided for in this section for the late

10-45  payment of an approved bill for accident benefits may not be waived.

10-46  7.  Payments made by an insurer pursuant to this section are not an

10-47  admission of liability for the accident benefits or any portion of the

10-48  accident benefits.

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

11-2  employer who provides accident benefits for injured employees pursuant

11-3  to NRS 616C.265 denies payment for some or all of the services itemized

11-4  on a statement submitted by a provider of health care on the sole basis

11-5  that those services were not related to the employee’s industrial injury or

11-6  occupational disease, the insurer, organization for managed care or

11-7  employer shall, at the same time that it sends notification to the provider

11-8  of health care of the denial, send a copy of the statement to the injured

11-9  employee and notify the injured employee that it has denied payment.

11-10  The notification sent to the injured employee must:

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

11-12  that the reason for denying payment is that the services were not related

11-13  to the industrial injury or occupational disease and that, pursuant to

11-14  subsection 2, the injured employee will be responsible for payment of the

11-15  relevant amount if he does not, in a timely manner, appeal the denial

11-16  pursuant to NRS 616C.305 and 616C.315 to 616C.385, inclusive, or

11-17  appeals but is not successful.

11-18  (b) Include an explanation of the injured employee’s right to request a

11-19  hearing to appeal the denial pursuant to NRS 616C.305 and 616C.315 to

11-20  616C.385, inclusive, and a suitable form for requesting a hearing to

11-21  appeal the denial.

11-22  2.  An injured employee who does not, in a timely manner, appeal the

11-23  denial of payment for the services rendered or who appeals the denial but

11-24  is not successful is responsible for payment of the relevant charges on

11-25  the itemized statement.

11-26  3.  To succeed on appeal, the injured employee must show that the:

11-27  (a) Services provided were related to the employee’s industrial injury

11-28  or occupational disease; or

11-29  (b) Insurer, organization for managed care or employer who provides

11-30  accident benefits for injured employees pursuant to NRS 616C.265 gave

11-31  prior authorization for the services rendered and did not withdraw that

11-32  prior authorization before the services of the provider of health care were

11-33  rendered.

11-34  Sec. 20. NRS 616C.065 is hereby amended to read as follows:

11-35  616C.065  1.  [Within] Except as otherwise provided in section 18 of

11-36  this act, within 30 days after the insurer has been notified of an industrial

11-37  accident, every insurer shall:

11-38  (a) Commence payment of a claim for compensation; or

11-39  (b) Deny the claim and notify the claimant and administrator that the

11-40  claim has been denied.

11-41  Payments made by an insurer pursuant to this section are not an admission

11-42  of liability for the claim or any portion of the claim.

11-43  2.  If an insurer unreasonably delays or refuses to pay that portion of

11-44  the claim for compensation that is not required to be paid pursuant to

11-45  section 18 of this act within 30 days after the insurer has been notified of

11-46  an industrial accident, the insurer shall pay upon order of the administrator

11-47  an additional amount equal to three times the amount specified in the order

11-48  as refused or unreasonably delayed. This payment is for the benefit of the

12-1  claimant and must be paid to him with the compensation assessed pursuant

12-2  to chapters 616A to 617, inclusive, of NRS.

12-3    Sec. 21. NRS 616C.135 is hereby amended to read as follows:

12-4    616C.135  1.  A provider of health care who accepts a patient as a

12-5  referral for the treatment of an industrial injury or an occupational disease

12-6  may not charge the patient for any treatment related to the industrial injury

12-7  or occupational disease, but must charge the insurer. The provider of health

12-8  care may charge the patient for any [other unrelated services which are

12-9  requested in writing by the patient.] services that are not related to the

12-10  employee’s industrial injury or occupational disease.

12-11  2.  The insurer is liable for the charges for approved services related to

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

12-13  (a) The fees established in accordance with NRS 616C.260 or the usual

12-14  fee charged by that person or institution, whichever is less; and

12-15  (b) The charges provided for by the contract between the provider of

12-16  health care and the insurer or the contract between the provider of health

12-17  care and the organization for managed care.

12-18  3.  If a provider of health care, an organization for managed care, an

12-19  insurer or an employer violates the provisions of this section, the

12-20  administrator shall impose an administrative fine of not more than $250 for

12-21  each violation.

12-22  Sec. 22.  If a different rate of interest has been established pursuant to

12-23  an express written contract between an administrator, insurer, carrier,

12-24  corporation or health maintenance organization and a provider of health

12-25  care, the amendatory provisions of sections 1.5, 3, 5, 7, 10, 11, 15 and 18

12-26  of this act, relating to the amount of interest that accrues if an approved

12-27  claim is not timely paid, apply only to contracts between the administrator,

12-28  insurer, carrier, corporation or health maintenance organization and the

12-29  provider of health care that are entered into or renewed on or after the

12-30  effective date of this act.

12-31  H