(REPRINTED WITH ADOPTED AMENDMENTS)
SECOND REPRINT S.B. 99
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 governing health insurance. (BDR 57‑132)
FISCAL NOTE: Effect on Local Government: No.
~
EXPLANATION
– Matter in bolded italics is new; matter
between brackets [omitted material] is material to be omitted.
Green numbers along left margin indicate location on the printed bill (e.g., 5-15 indicates page 5, line 15).
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; 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.
2-1 (b) “Health care plan” means a policy, contract, certificate or agreement
2-2 offered or issued by an insurer to provide, deliver, arrange for, pay for or
2-3 reimburse any of the costs of health care services.
2-4 Sec. 1.5. NRS 683A.0879 is hereby amended to read as follows:
2-5 683A.0879 1. Except as otherwise provided in subsection 2, an
2-6 administrator shall approve or deny a claim relating to health insurance
2-7 coverage within 30 days after the administrator receives the claim. If the
2-8 claim is approved, the administrator shall pay the claim within 30 days
2-9 after it is approved. If the approved claim is not paid within that period, the
2-10 administrator shall pay interest on the claim at [the] a rate of interest
2-11 [established pursuant to NRS 99.040 unless a different rate of interest is
2-12 established pursuant to an express written contract between the
2-13 administrator and the provider of health care.] equal to the prime rate at
2-14 the largest bank in Nevada, as ascertained by the commissioner of
2-15 financial institutions, on January 1 or July 1, as the case may be,
2-16 immediately preceding the date on which the payment was due, plus 6
2-17 percent. The interest must be calculated from 30 days after the date on
2-18 which the claim is approved until the date on which the claim is paid.
2-19 2. If the administrator requires additional information to determine
2-20 whether to approve or deny the claim, he shall notify the claimant of his
2-21 request for the additional information within 20 days after he receives the
2-22 claim. The administrator shall notify the provider of health care of all the
2-23 specific reasons for the delay in approving or denying the claim. The
2-24 administrator shall approve or deny the claim within 30 days after
2-25 receiving the additional information. If the claim is approved, the
2-26 administrator shall pay the claim within 30 days after he receives the
2-27 additional information. If the approved claim is not paid within that period,
2-28 the administrator shall pay interest on the claim in the manner prescribed in
2-29 subsection 1.
2-30 3. An administrator shall not request a claimant to resubmit
2-31 information that the claimant has already provided to the administrator,
2-32 unless the administrator provides a legitimate reason for the request and the
2-33 purpose of the request is not to delay the payment of the claim, harass the
2-34 claimant or discourage the filing of claims.
2-35 4. An administrator shall not pay only part of a claim that has been
2-36 approved and is fully payable.
2-37 5. A court shall award costs and reasonable attorney’s fees to the
2-38 prevailing party in an action brought pursuant to this section.
2-39 6. An administrator shall not require a provider of health care to
2-40 waive the payment of interest provided for in this section for the late
2-41 payment of an approved claim.
2-42 7. The commissioner may require an administrator to provide
2-43 evidence which demonstrates that the administrator has substantially
2-44 complied with the requirements set forth in this section, including,
2-45 without limitation, payment within 30 days of at least 95 percent of
2-46 approved claims or at least 90 percent of the total dollar amount for
2-47 approved claims. If the commissioner determines that an administrator is
2-48 not in substantial compliance with the requirements set forth in this
3-1 section, the commissioner may require the administrator to pay an
3-2 administrative fine in an amount to be determined by the commissioner.
3-3 Sec. 2. NRS 689A.035 is hereby amended to read as follows:
3-4 689A.035 An insurer [may] shall not charge a provider of health care
3-5 a fee to include the name of the provider on a list of providers of health
3-6 care given by the insurer to its insureds. [The amount of the fee must be
3-7 reasonable and must not exceed an amount that is directly related to the
3-8 administrative costs of the insurer to include the provider on the list.]
3-9 Sec. 3. NRS 689A.410 is hereby amended to read as follows:
3-10 689A.410 1. Except as otherwise provided in subsection 2, an insurer
3-11 shall approve or deny a claim relating to a policy of health insurance within
3-12 30 days after the insurer receives the claim. If the claim is approved, the
3-13 insurer shall pay the claim within 30 days after it is approved. If the
3-14 approved claim is not paid within that period, the insurer shall pay interest
3-15 on the claim at [the] a rate of interest [established pursuant to NRS 99.040
3-16 unless a different rate of interest is established pursuant to an express
3-17 written contract between the insurer and the provider of health care.] equal
3-18 to the prime rate at the largest bank in Nevada, as ascertained by the
3-19 commissioner of financial institutions, on January 1 or July 1, as the
3-20 case may be, immediately preceding the date on which the payment was
3-21 due, plus 6 percent. The interest must be calculated from 30 days after the
3-22 date on which the claim is approved until the date on which the claim is
3-23 paid.
3-24 2. If the insurer requires additional information to determine whether
3-25 to approve or deny the claim, it shall notify the claimant of its request for
3-26 the additional information within 20 days after it receives the claim. The
3-27 insurer shall notify the provider of health care of all the specific reasons for
3-28 the delay in approving or denying the claim. The insurer shall approve or
3-29 deny the claim within 30 days after receiving the additional information. If
3-30 the claim is approved, the insurer shall pay the claim within 30 days after it
3-31 receives the additional information. If the approved claim is not paid within
3-32 that period, the insurer shall pay interest on the claim in the manner
3-33 prescribed in subsection 1.
3-34 3. An insurer shall not request a claimant to resubmit information that
3-35 the claimant has already provided to the insurer, unless the insurer provides
3-36 a legitimate reason for the request and the purpose of the request is not to
3-37 delay the payment of the claim, harass the claimant or discourage the filing
3-38 of claims.
3-39 4. An insurer shall not pay only part of a claim that has been approved
3-40 and is fully payable.
3-41 5. A court shall award costs and reasonable attorney’s fees to the
3-42 prevailing party in an action brought pursuant to this section.
3-43 6. An insurer shall not require a provider of health care to waive the
3-44 payment of interest provided for in this section for the late payment of an
3-45 approved claim.
3-46 7. The commissioner may require an insurer to provide evidence
3-47 which demonstrates that the insurer has substantially complied with the
3-48 requirements set forth in this section, including, without limitation,
3-49 payment within 30 days of at least 95 percent of approved claims or at
4-1 least 90 percent of the total dollar amount for approved claims. If the
4-2 commissioner determines that an insurer is not in substantial compliance
4-3 with the requirements set forth in this section, the commissioner may
4-4 require the insurer to pay an administrative fine in an amount to be
4-5 determined by the commissioner.
4-6 Sec. 4. NRS 689B.015 is hereby amended to read as follows:
4-7 689B.015 An insurer that issues a policy of group health insurance
4-8 [may] shall not charge a provider of health care a fee to include the name
4-9 of the provider on a list of providers of health care given by the insurer to
4-10 its insureds. [The amount of the fee must be reasonable and must not
4-11 exceed an amount that is directly related to the administrative costs of the
4-12 insurer to include the provider on the list.]
4-13 Sec. 5. NRS 689B.255 is hereby amended to read as follows:
4-14 689B.255 1. Except as otherwise provided in subsection 2, an insurer
4-15 shall approve or deny a claim relating to a policy of group health insurance
4-16 or blanket insurance within 30 days after the insurer receives the claim. If
4-17 the claim is approved, the insurer shall pay the claim within 30 days after it
4-18 is approved. If the approved claim is not paid within that period, the insurer
4-19 shall pay interest on the claim at [the] a rate of interest [established
4-20 pursuant to NRS 99.040 unless a different rate of interest is established
4-21 pursuant to an express written contract between the insurer and the
4-22 provider of health care.] equal to the prime rate at the largest bank in
4-23 Nevada, as ascertained by the commissioner of financial institutions, on
4-24 January 1 or July 1, as the case may be, immediately preceding the date
4-25 on which the payment was due, plus 6 percent. The interest must be
4-26 calculated from 30 days after the date on which the claim is approved until
4-27 the date on which the claim is paid.
4-28 2. If the insurer requires additional information to determine whether
4-29 to approve or deny the claim, it shall notify the claimant of its request for
4-30 the additional information within 20 days after it receives the claim. The
4-31 insurer shall notify the provider of health care of all the specific reasons for
4-32 the delay in approving or denying the claim. The insurer shall approve or
4-33 deny the claim within 30 days after receiving the additional information. If
4-34 the claim is approved, the insurer shall pay the claim within 30 days after it
4-35 receives the additional information. If the approved claim is not paid within
4-36 that period, the insurer shall pay interest on the claim in the manner
4-37 prescribed in subsection 1.
4-38 3. An insurer shall not request a claimant to resubmit information that
4-39 the claimant has already provided to the insurer, unless the insurer provides
4-40 a legitimate reason for the request and the purpose of the request [in] is not
4-41 to delay the payment of the claim, harass the claimant or discourage the
4-42 filing of claims.
4-43 4. An insurer shall not pay only part of a claim that has been approved
4-44 and is fully payable.
4-45 5. A court shall award costs and reasonable attorney’s fees to the
4-46 prevailing party in an action brought pursuant to this section.
4-47 6. An insurer shall not require a provider of health care to waive the
4-48 payment of interest provided for in this section for the late payment of an
4-49 approved claim.
5-1 7. The commissioner may require an insurer to provide evidence
5-2 which demonstrates that the insurer has substantially complied with the
5-3 requirements set forth in this section, including, without limitation,
5-4 payment within 30 days of at least 95 percent of approved claims or at
5-5 least 90 percent of the total dollar amount for approved claims. If the
5-6 commissioner determines that an insurer is not in substantial compliance
5-7 with the requirements set forth in this section, the commissioner may
5-8 require the insurer to pay an administrative fine in an amount to be
5-9 determined by the commissioner.
5-10 Sec. 6. NRS 689C.435 is hereby amended to read as follows:
5-11 689C.435 A carrier serving small employers and a carrier that offers a
5-12 contract to a voluntary purchasing group [may] shall not charge a provider
5-13 of health care a fee to include the name of the provider on a list of
5-14 providers of health care given by the carrier to its insureds. [The amount of
5-15 the fee must be reasonable and must not exceed an amount that is directly
5-16 related to the administrative costs of the carrier to include the provider on
5-17 the list.]
5-18 Sec. 7. NRS 689C.485 is hereby amended to read as follows:
5-19 689C.485 1. Except as otherwise provided in subsection 2, a carrier
5-20 serving small employers and a carrier that offers a contract to a voluntary
5-21 purchasing group shall approve or deny a claim relating to a policy of
5-22 health insurance within 30 days after the carrier receives the claim. If the
5-23 claim is approved, the carrier shall pay the claim within 30 days after it is
5-24 approved. If the approved claim is not paid within that period, the carrier
5-25 shall pay interest on the claim at [the] a rate of interest [established
5-26 pursuant to NRS 99.040 unless a different rate of interest is established
5-27 pursuant to an express written contract between the carrier and the provider
5-28 of health care.] equal to the prime rate at the largest bank in Nevada, as
5-29 ascertained by the commissioner of financial institutions, on January 1
5-30 or July 1, as the case may be, immediately preceding the date on which
5-31 the payment was due, plus 6 percent. The interest must be calculated from
5-32 30 days after the date on which the claim is approved until the date on
5-33 which the claim is paid.
5-34 2. If the carrier requires additional information to determine whether to
5-35 approve or deny the claim, it shall notify the claimant of its request for the
5-36 additional information within 20 days after it receives the claim. The
5-37 carrier shall notify the provider of health care of all the specific reasons for
5-38 the delay in approving or denying the claim. The carrier shall approve or
5-39 deny the claim within 30 days after receiving the additional information. If
5-40 the claim is approved, the carrier shall pay the claim within 30 days after it
5-41 receives the additional information. If the approved claim is not paid within
5-42 that period, the carrier shall pay interest on the claim in the manner
5-43 prescribed in subsection 1.
5-44 3. A carrier shall not request a claimant to resubmit information that
5-45 the claimant has already provided to the carrier, unless the carrier provides
5-46 a legitimate reason for the request and the purpose of the request is not to
5-47 delay the payment of the claim, harass the claimant or discourage the filing
5-48 of claims.
6-1 4. A carrier shall not pay only part of a claim that has been approved
6-2 and is fully payable.
6-3 5. A court shall award costs and reasonable attorney’s fees to the
6-4 prevailing party in an action brought pursuant to this section.
6-5 6. A carrier shall not require a provider of health care to waive the
6-6 payment of interest provided for in this section for the late payment of an
6-7 approved claim.
6-8 7. The commissioner may require a carrier to provide evidence
6-9 which demonstrates that the carrier has substantially complied with the
6-10 requirements set forth in this section, including, without limitation,
6-11 payment within 30 days of at least 95 percent of approved claims or at
6-12 least 90 percent of the total dollar amount for approved claims. If the
6-13 commissioner determines that a carrier is not in substantial compliance
6-14 with the requirements set forth in this section, the commissioner may
6-15 require the carrier to pay an administrative fine in an amount to be
6-16 determined by the commissioner.
6-17 Sec. 8. NRS 695A.095 is hereby amended to read as follows:
6-18 695A.095 A society [may] shall not charge a provider of health care a
6-19 fee to include the name of the provider on a list of providers of health care
6-20 given by the society to its insureds. [The amount of the fee must be
6-21 reasonable and must not exceed an amount that is directly related to the
6-22 administrative costs of the society to include the provider on the list.]
6-23 Sec. 9. NRS 695B.035 is hereby amended to read as follows:
6-24 695B.035 A corporation subject to the provisions of this chapter [may]
6-25 shall not charge a provider of health care a fee to include the name of the
6-26 provider on a list of providers of health care given by the corporation to its
6-27 insureds. [The amount of the fee must be reasonable and must not exceed
6-28 an amount that is directly related to the administrative costs of the
6-29 corporation to include the provider on the list.]
6-30 Sec. 10. NRS 695B.2505 is hereby amended to read as follows:
6-31 695B.2505 1. Except as otherwise provided in subsection 2, a
6-32 corporation subject to the provisions of this chapter shall approve or deny a
6-33 claim relating to a contract for dental, hospital or medical services within
6-34 30 days after the corporation receives the claim. If the claim is approved,
6-35 the corporation shall pay the claim within 30 days after it is approved. If
6-36 the approved claim is not paid within that period, the corporation shall pay
6-37 interest on the claim at [the] a rate of interest [established pursuant to NRS
6-38 99.040 unless a different rate of interest is established pursuant to an
6-39 express written contract between the corporation and the provider of health
6-40 care.] equal to the prime rate at the largest bank in Nevada, as
6-41 ascertained by the commissioner of financial institutions, on January 1
6-42 or July 1, as the case may be, immediately preceding the date on which
6-43 the payment was due, plus 6 percent. The interest must be calculated from
6-44 30 days after the date on which the claim is approved until the date on
6-45 which the claim is paid.
6-46 2. If the corporation requires additional information to determine
6-47 whether to approve or deny the claim, it shall notify the claimant of its
6-48 request for the additional information within 20 days after it receives the
6-49 claim. The corporation shall notify the provider of dental, hospital or
7-1 medical services of all the specific reasons for the delay in approving or
7-2 denying the claim. The corporation shall approve or deny the claim within
7-3 30 days after receiving the additional information. If the claim is approved,
7-4 the corporation shall pay the claim within 30 days after it receives the
7-5 additional information. If the approved claim is not paid within that period,
7-6 the corporation shall pay interest on the claim in the manner prescribed in
7-7 subsection 1.
7-8 3. A corporation shall not request a claimant to resubmit information
7-9 that the claimant has already provided to the corporation, unless the
7-10 corporation provides a legitimate reason for the request and the purpose of
7-11 the request is not to delay the payment of the claim, harass the claimant or
7-12 discourage the filing of claims.
7-13 4. A corporation shall not pay only part of a claim that has been
7-14 approved and is fully payable.
7-15 5. A court shall award costs and reasonable attorney’s fees to the
7-16 prevailing party in an action brought pursuant to this section.
7-17 6. A corporation shall not require a provider of health care to waive
7-18 the payment of interest provided for in this section for the late payment of
7-19 an approved claim.
7-20 7. The commissioner may require a corporation to provide evidence
7-21 which demonstrates that the corporation has substantially complied with
7-22 the requirements set forth in this section, including, without limitation,
7-23 payment within 30 days of at least 95 percent of approved claims or at
7-24 least 90 percent of the total dollar amount for approved claims. If the
7-25 commissioner determines that a corporation is not in substantial
7-26 compliance with the requirements set forth in this section, the
7-27 commissioner may require the corporation to pay an administrative fine
7-28 in an amount to be determined by the commissioner.
7-29 Sec. 11. Chapter 695C of NRS is hereby amended by adding thereto
7-30 the provisions set forth as sections 11.3 and 11.7 of this act.
7-31 Sec. 11.3. 1. A health maintenance organization shall not:
7-32 (a) Enter into any contract or agreement, or make any other
7-33 arrangements, with a provider for the provision of health care; or
7-34 (b) Employ a provider pursuant to a contract, an agreement or any
7-35 other arrangement to provide health care,
7-36 unless the contract, agreement or other arrangement specifically
7-37 provides that the health maintenance organization and provider agree to
7-38 the schedule for the payment of claims set forth in NRS 695C.185.
7-39 2. Any contract, agreement or other arrangement between a health
7-40 maintenance organization and a provider that is entered into or renewed
7-41 on or after October 1, 2001, that does not specifically include a provision
7-42 concerning the schedule for the payment of claims as required by
7-43 subsection 1 shall be deemed to conform with the requirements of
7-44 subsection 1 by operation of law.
7-45 Sec. 11.7. Any contract or other agreement entered into or renewed
7-46 by a health maintenance organization on or after October 1, 2001:
7-47 1. To provide health care services through managed care to
7-48 recipients of Medicaid under the state plan for Medicaid; or
8-1 2. With the division of health care financing and policy of the
8-2 department of human resources to provide insurance pursuant to the
8-3 children’s health insurance program,
8-4 must require the health maintenance organization to pay interest to a
8-5 provider of health care services on a claim that is not paid within the
8-6 time provided in the contract or agreement at a rate of interest equal to
8-7 the prime rate at the largest bank in Nevada, as ascertained by the
8-8 commissioner of financial institutions, on January 1 or July 1, as the
8-9 case may be, immediately preceding the date on which the payment was
8-10 due, plus 6 percent. The interest must be calculated from 30 days after
8-11 the date on which the claim is approved until the date on which the claim
8-12 is paid.
8-13 Sec. 12. NRS 695C.050 is hereby amended to read as follows:
8-14 695C.050 1. Except as otherwise provided in this chapter or in
8-15 specific provisions of this Title, the provisions of this Title are not
8-16 applicable to any health maintenance organization granted a certificate of
8-17 authority under this chapter. This provision does not apply to an insurer
8-18 licensed and regulated pursuant to this Title except with respect to its
8-19 activities as a health maintenance organization authorized and regulated
8-20 pursuant to this chapter.
8-21 2. Solicitation of enrollees by a health maintenance organization
8-22 granted a certificate of authority, or its representatives, must not be
8-23 construed to violate any provision of law relating to solicitation or
8-24 advertising by practitioners of a healing art.
8-25 3. Any health maintenance organization authorized under this chapter
8-26 shall not be deemed to be practicing medicine and is exempt from the
8-27 provisions of chapter 630 of NRS.
8-28 4. The provisions of NRS 695C.110, 695C.170 to 695C.200, inclusive,
8-29 [and] sections 19 and 20 of [this act,] Senate Bill No. 2 of this session,
8-30 section 11.3 of this act and NRS695C.250 and 695C.265 do not apply to a
8-31 health maintenance organization that provides health care services through
8-32 managed care to recipients of Medicaid under the state plan for Medicaid
8-33 or insurance pursuant to the children’s health insurance program pursuant
8-34 to a contract with the division of health care financing and policy of the
8-35 department of human resources. This subsection does not exempt a health
8-36 maintenance organization from any provision of this chapter for services
8-37 provided pursuant to any other contract.
8-38 5. The provisions of NRS 695C.1694 and 695C.1695 apply to a health
8-39 maintenance organization that provides health care services through
8-40 managed care to recipients of Medicaid under the state plan for Medicaid.
8-41 Sec. 13. NRS 695C.055 is hereby amended to read as follows:
8-42 695C.055 1. The provisions of NRS 449.465, 679B.158, subsections
8-43 2, 4, 18, 19 and 32 of NRS 680B.010, NRS 680B.025 to 680B.060,
8-44 inclusive, [and 695G.010 to 695G.260, inclusive,] chapter 695G of NRS
8-45 and section 16 of this act, apply to a health maintenance organization.
8-46 2. For the purposes of subsection 1, unless the context requires that a
8-47 provision apply only to insurers, any reference in those sections to
8-48 “insurer” must be replaced by “health maintenance organization.”
9-1 Sec. 14. NRS 695C.125 is hereby amended to read as follows:
9-2 695C.125 A health maintenance organization [may] shall not charge a
9-3 provider of health care a fee to include the name of the provider on a list of
9-4 providers of health care given by the health maintenance organization to its
9-5 enrollees. [The amount of the fee must be reasonable and must not exceed
9-6 an amount that is directly related to the administrative costs of the health
9-7 maintenance organization to include the provider on the list.]
9-8 Sec. 15. NRS 695C.185 is hereby amended to read as follows:
9-9 695C.185 1. Except as otherwise provided in subsection 2, a health
9-10 maintenance organization shall approve or deny a claim relating to a health
9-11 care plan within 30 days after the health maintenance organization receives
9-12 the claim. If the claim is approved, the health maintenance organization
9-13 shall pay the claim within 30 days after it is approved. If the approved
9-14 claim is not paid within that period, the health maintenance organization
9-15 shall pay interest on the claim at [the] a rate of interest [established
9-16 pursuant to NRS 99.040 unless a different rate of interest is established
9-17 pursuant to an express written contract between the health maintenance
9-18 organization and the provider of health care.] equal to the prime rate at the
9-19 largest bank in Nevada, as ascertained by the commissioner of financial
9-20 institutions, on January 1 or July 1, as the case may be, immediately
9-21 preceding the date on which the payment was due, plus 6 percent. The
9-22 interest must be calculated from 30 days after the date on which the claim
9-23 is approved until the date on which the claim is paid.
9-24 2. If the health maintenance organization requires additional
9-25 information to determine whether to approve or deny the claim, it shall
9-26 notify the claimant of its request for the additional information within 20
9-27 days after it receives the claim. The health maintenance organization shall
9-28 notify the provider of health care services of all the specific reasons for the
9-29 delay in approving or denying the claim. The health maintenance
9-30 organization shall approve or deny the claim within 30 days after receiving
9-31 the additional information. If the claim is approved, the health maintenance
9-32 organization shall pay the claim within 30 days after it receives the
9-33 additional information. If the approved claim is not paid within that period,
9-34 the health maintenance organization shall pay interest on the claim in the
9-35 manner prescribed in subsection 1.
9-36 3. A health maintenance organization shall not request a claimant to
9-37 resubmit information that the claimant has already provided to the health
9-38 maintenance organization, unless the health maintenance organization
9-39 provides a legitimate reason for the request and the purpose of the request
9-40 is not to delay the payment of the claim, harass the claimant or discourage
9-41 the filing of claims.
9-42 4. A health maintenance organization shall not pay only part of a claim
9-43 that has been approved and is fully payable.
9-44 5. A court shall award costs and reasonable attorney’s fees to the
9-45 prevailing party in an action brought pursuant to this section.
9-46 6. A health maintenance organization shall not require a provider of
9-47 health care services to waive the payment of interest provided for in this
9-48 section for the late payment of an approved claim.
10-1 7. The commissioner may require a health maintenance organization
10-2 to provide evidence which demonstrates that the health maintenance
10-3 organization has substantially complied with the requirements set forth
10-4 in this section, including, without limitation, payment within 30 days of
10-5 at least 95 percent of approved claims or at least 90 percent of the total
10-6 dollar amount for approved claims. If the commissioner determines that
10-7 a health maintenance organization is not in substantial compliance with
10-8 the requirements set forth in this section, the commissioner may require
10-9 the health maintenance organization to pay an administrative fine in an
10-10 amount to be determined by the commissioner.
10-11 Sec. 16. Chapter 695G of NRS is hereby amended by adding thereto a
10-12 new section to read as follows:
10-13 A managed care organization that establishes a panel of providers of
10-14 health care for the purpose of offering health care services pursuant to
10-15 chapter 689A, 689B, 689C, 695A, 695B or 695C of NRS shall not charge
10-16 a provider of health care a fee to include the name of the provider on the
10-17 panel of providers of health care.
10-18 Sec. 17. Chapter 616C of NRS is hereby amended by adding thereto
10-19 the provisions set forth as sections 18 and 19 of this act.
10-20 Sec. 18. 1. Except as otherwise provided in this section, an insurer
10-21 shall approve or deny a bill for accident benefits received from a provider
10-22 of health care within 30 calendar days after the insurer receives the bill.
10-23 If the bill for accident benefits is approved, the insurer shall pay the bill
10-24 within 30 calendar days after it is approved. If the approved bill for
10-25 accident benefits is not paid within that period, the insurer shall pay
10-26 interest to the provider of health care at a rate of interest equal to the
10-27 prime rate at the largest bank in Nevada, as ascertained by the
10-28 commissioner of financial institutions, on January 1 or July 1, as the
10-29 case may be, immediately preceding the date on which the payment was
10-30 due, plus 6 percent. The interest must be calculated from 30 calendar
10-31 days after the date on which the bill is approved until the date on which
10-32 the bill is paid.
10-33 2. If an insurer needs additional information to determine whether to
10-34 approve or deny a bill for accident benefits received from a provider of
10-35 health care, he shall notify the provider of health care of his request for
10-36 the additional information within 20 calendar days after he receives the
10-37 bill. The insurer shall notify the provider of health care of all the specific
10-38 reasons for the delay in approving or denying the bill for accident
10-39 benefits. Upon the receipt of such a request, the provider of health care
10-40 shall furnish the additional information to the insurer within 20 calendar
10-41 days after receiving the request. If the provider of health care fails to
10-42 furnish the additional information within that period, the provider of
10-43 health care is not entitled to the payment of interest to which he would
10-44 otherwise be entitled for the late payment of the bill for accident benefits.
10-45 The insurer shall approve or deny the bill for accident benefits within 20
10-46 calendar days after he receives the additional information. If the bill for
10-47 accident benefits is approved, the insurer shall pay the bill within 20
10-48 calendar days after he receives the additional information. Except as
10-49 otherwise provided in this subsection, if the approved bill for accident
11-1 benefits is not paid within that period, the insurer shall pay interest to the
11-2 provider of health care at the rate set forth in subsection 1. The interest
11-3 must be calculated from 20 calendar days after the date on which the
11-4 insurer receives the additional information until the date on which the
11-5 bill is paid.
11-6 3. An insurer shall not request a provider of health care to resubmit
11-7 information that the provider of health care has previously provided to
11-8 the insurer, unless the insurer provides a legitimate reason for the
11-9 request and the purpose of the request is not to delay the payment of the
11-10 accident benefits, harass the provider of health care or discourage the
11-11 filing of claims.
11-12 4. An insurer shall not pay only a portion of a bill for accident
11-13 benefits that has been approved and is fully payable.
11-14 5. The administrator may require an insurer to provide evidence
11-15 which demonstrates that the insurer has substantially complied with the
11-16 requirements of this section, including, without limitation, payment
11-17 within the time required of at least 95 percent of approved accident
11-18 benefits or at least 90 percent of the total dollar amount of approved
11-19 accident benefits. If the administrator determines that an insurer is not
11-20 in substantial compliance with the requirements of this section, the
11-21 administrator may require the insurer to pay an administrative fine in an
11-22 amount to be determined by the administrator.
11-23 6. An insurer shall not require a provider of health care to waive the
11-24 payment of interest provided for in this section for the late payment of an
11-25 approved claim.
11-26 7. Payments made by an insurer pursuant to this section are not an
11-27 admission of liability for the accident benefits or any portion of the
11-28 accident benefits.
11-29 Sec. 19. 1. If an insurer, organization for managed care or
11-30 employer who provides accident benefits for injured employees pursuant
11-31 to NRS 616C.265 denies payment for some or all of the services itemized
11-32 on a statement submitted by a provider of health care on the sole basis
11-33 that those services were not related to the employee’s industrial injury or
11-34 occupational disease, the insurer, organization for managed care or
11-35 employer shall, at the same time that it sends notification to the provider
11-36 of health care of the denial, send a copy of the statement to the injured
11-37 employee and notify the injured employee that it has denied payment.
11-38 The notification sent to the injured employee must:
11-39 (a) State the relevant amount requested as payment in the statement,
11-40 that the reason for denying payment is that the services were not related
11-41 to the industrial injury or occupational disease and that, pursuant to
11-42 subsection 2, the injured employee will be responsible for payment of the
11-43 relevant amount if he does not, in a timely manner, appeal the denial
11-44 pursuant to NRS 616C.305 and 616C.315 to 616C.385, inclusive, or
11-45 appeals but is not successful.
11-46 (b) Include an explanation of the injured employee’s right to request a
11-47 hearing to appeal the denial pursuant to NRS 616C.305 and 616C.315 to
11-48 616C.385, inclusive, and a suitable form for requesting a hearing to
11-49 appeal the denial.
12-1 2. An injured employee who does not, in a timely manner, appeal the
12-2 denial of payment for the services rendered or who appeals the denial but
12-3 is not successful is responsible for payment of the relevant charges on
12-4 the itemized statement.
12-5 3. To succeed on appeal, the injured employee must show that the:
12-6 (a) Services provided were related to the employee’s industrial injury
12-7 or occupational disease; or
12-8 (b) Insurer, organization for managed care or employer who provides
12-9 accident benefits for injured employees pursuant to NRS 616C.265 gave
12-10 prior authorization for the services rendered and did not withdraw that
12-11 prior authorization before the services of the provider of health care were
12-12 rendered.
12-13 Sec. 20. NRS 616C.065 is hereby amended to read as follows:
12-14 616C.065 1. [Within] Except as otherwise provided in section 18 of
12-15 this act, within 30 days after the insurer has been notified of an industrial
12-16 accident, every insurer shall:
12-17 (a) Commence payment of a claim for compensation; or
12-18 (b) Deny the claim and notify the claimant and administrator that the
12-19 claim has been denied.
12-20 Payments made by an insurer pursuant to this section are not an admission
12-21 of liability for the claim or any portion of the claim.
12-22 2. [If] Except as otherwise provided in this subsection, if an insurer
12-23 unreasonably delays or refuses to pay the claim within 30 days after the
12-24 insurer has been notified of an industrial accident, the insurer shall pay
12-25 upon order of the administrator an additional amount equal to three times
12-26 the amount specified in the order as refused or unreasonably delayed. This
12-27 payment is for the benefit of the claimant and must be paid to him with the
12-28 compensation assessed pursuant to chapters 616A to 617, inclusive, of
12-29 NRS. The provisions of this section do not apply to the payment of a bill
12-30 for accident benefits that is governed by the provisions of section 18 of
12-31 this act.
12-32 Sec. 21. NRS 616C.135 is hereby amended to read as follows:
12-33 616C.135 1. A provider of health care who accepts a patient as a
12-34 referral for the treatment of an industrial injury or an occupational disease
12-35 may not charge the patient for any treatment related to the industrial injury
12-36 or occupational disease, but must charge the insurer. The provider of health
12-37 care may charge the patient for any [other unrelated services which are
12-38 requested in writing by the patient.] services that are not related to the
12-39 employee’s industrial injury or occupational disease.
12-40 2. The insurer is liable for the charges for approved services related to
12-41 the industrial injury or occupational disease if the charges do not exceed:
12-42 (a) The fees established in accordance with NRS 616C.260 or the usual
12-43 fee charged by that person or institution, whichever is less; and
12-44 (b) The charges provided for by the contract between the provider of
12-45 health care and the insurer or the contract between the provider of health
12-46 care and the organization for managed care.
12-47 3. If a provider of health care, an organization for managed care, an
12-48 insurer or an employer violates the provisions of this section, the
13-1 administrator shall impose an administrative fine of not more than $250 for
13-2 each violation.
13-3 Sec. 22. NRS 616C.220 is hereby amended to read as follows:
13-4 616C.220 1. The division shall designate one:
13-5 (a) Third-party administrator who has a valid certificate issued by the
13-6 commissioner pursuant to NRS 683A.085; or
13-7 (b) Insurer, other than a self-insured employer or association of self-
13-8 insured public or private employers,
13-9 to administer claims against the uninsured employers’ claim fund. The
13-10 designation must be made pursuant to reasonable competitive bidding
13-11 procedures established by the administrator.
13-12 2. An employee may receive compensation from the uninsured
13-13 employers’ claim fund if:
13-14 (a) He was hired in this state or he is regularly employed in this state;
13-15 (b) He suffers an accident or injury [in this state] which arises out of
13-16 and in the course of his employment;
13-17 (c) He files a claim for compensation with the division; and
13-18 (d) He makes an irrevocable assignment to the division of a right to be
13-19 subrogated to the rights of the injured employee pursuant to
13-20 NRS 616C.215.
13-21 3. If the division receives a claim pursuant to subsection 2, the division
13-22 shall immediately notify the employer of the claim.
13-23 4. For the purposes of this section, the employer has the burden of
13-24 proving that he provided mandatory industrial insurance coverage for the
13-25 employee or that he was not required to maintain industrial insurance for
13-26 the employee.
13-27 5. Any employer who has failed to provide mandatory coverage
13-28 required by the provisions of chapters 616A to 616D, inclusive, of NRS is
13-29 liable for all payments made on his behalf, including any benefits,
13-30 administrative costs or attorney’s fees paid from the uninsured employers’
13-31 claim fund or incurred by the division.
13-32 6. The division:
13-33 (a) May recover from the employer the payments made by the division
13-34 that are described in subsection 5 and any accrued interest by bringing a
13-35 civil action in district court.
13-36 (b) In any civil action brought against the employer, is not required to
13-37 prove that negligent conduct by the employer was the cause of the
13-38 employee’s injury.
13-39 (c) May enter into a contract with any person to assist in the collection
13-40 of any liability of an uninsured employer.
13-41 (d) In lieu of a civil action, may enter into an agreement or settlement
13-42 regarding the collection of any liability of an uninsured employer.
13-43 7. The division shall:
13-44 (a) Determine whether the employer was insured within 30 days after
13-45 receiving notice of the claim from the employee.
13-46 (b) Assign the claim to the third-party administrator or insurer
13-47 designated pursuant to subsection 1 for administration and payment of
13-48 compensation.
14-1 Upon determining whether the claim is accepted or denied, the designated
14-2 third-party administrator or insurer shall notify the injured employee, the
14-3 named employer and the division of its determination.
14-4 8. Upon demonstration of the:
14-5 (a) Costs incurred by the designated third-party administrator or insurer
14-6 to administer the claim or pay compensation to the injured employee; or
14-7 (b) Amount that the designated third-party administrator or insurer will
14-8 pay for administrative expenses or compensation to the injured employee
14-9 and that such amounts are justified by the circumstances of the
14-10 claim,
14-11 the division shall authorize payment from the uninsured employers’ claim
14-12 fund.
14-13 9. Any party aggrieved by a determination regarding the
14-14 administration of an assigned claim or a determination made by the
14-15 division or by the designated third-party administrator or insurer regarding
14-16 any claim made pursuant to this section may appeal that determination
14-17 within 60 days after the determination is rendered to the hearings division
14-18 of the department of administration in the manner provided by NRS
14-19 616C.305 and 616C.315 to 616C.385, inclusive.
14-20 10. All insurers shall bear a proportionate amount of a claim made
14-21 pursuant to chapters 616A to 616D, inclusive, of NRS, and are entitled to a
14-22 proportionate amount of any collection made pursuant to this section as an
14-23 offset against future liabilities.
14-24 11. An uninsured employer is liable for the interest on any amount
14-25 paid on his claims from the uninsured employers’ claim fund. The interest
14-26 must be calculated at a rate equal to the prime rate at the largest bank in
14-27 Nevada, as ascertained by the commissioner of financial institutions, on
14-28 January 1 or July 1, as the case may be, immediately preceding the date of
14-29 the claim, plus 3 percent, compounded monthly, from the date the claim is
14-30 paid from the fund until payment is received by the division from the
14-31 employer.
14-32 12. Attorney’s fees recoverable by the division pursuant to this section
14-33 must be:
14-34 (a) If a private attorney is retained by the division, paid at the usual and
14-35 customary rate for that attorney.
14-36 (b) If the attorney is an employee of the division, paid at the rate
14-37 established by regulations adopted by the division.
14-38 Any money collected must be deposited to the uninsured employers’ claim
14-39 fund.
14-40 13. In addition to any other liabilities provided for in this section, the
14-41 administrator may impose an administrative fine of not more than $10,000
14-42 against an employer if the employer fails to provide mandatory coverage
14-43 required by the provisions of chapters 616A to 616D, inclusive, of NRS.
14-44 Sec. 23. NRS 617.401 is hereby amended to read as follows:
14-45 617.401 1. The division shall designate one:
14-46 (a) Third-party administrator who has a valid certificate issued by the
14-47 commissioner pursuant to NRS 683A.085; or
14-48 (b) Insurer, other than a self-insured employer or association of self-
14-49 insured public or private employers,
15-1 to administer claims against the uninsured employers’ claim fund. The
15-2 designation must be made pursuant to reasonable competitive bidding
15-3 procedures established by the administrator.
15-4 2. An employee may receive compensation from the uninsured
15-5 employers’ claim fund if:
15-6 (a) He was hired in this state or he is regularly employed in this state;
15-7 (b) He contracts an occupational disease [as a result of work performed
15-8 in this state;] that arose out of and in the course of employment;
15-9 (c) He files a claim for compensation with the division; and
15-10 (d) He makes an irrevocable assignment to the division of a right to be
15-11 subrogated to the rights of the employee pursuant to NRS 616C.215.
15-12 3. If the division receives a claim pursuant to subsection 2, the division
15-13 shall immediately notify the employer of the claim.
15-14 4. For the purposes of this section, the employer has the burden of
15-15 proving that he provided mandatory coverage for occupational diseases for
15-16 the employee or that he was not required to maintain industrial insurance
15-17 for the employee.
15-18 5. Any employer who has failed to provide mandatory coverage
15-19 required by the provisions of this chapter is liable for all payments made on
15-20 his behalf, including, but not limited to, any benefits, administrative costs
15-21 or attorney’s fees paid from the uninsured employers’ claim fund or
15-22 incurred by the division.
15-23 6. The division:
15-24 (a) May recover from the employer the payments made by the division
15-25 that are described in subsection 5 and any accrued interest by bringing a
15-26 civil action in district court.
15-27 (b) In any civil action brought against the employer, is not required to
15-28 prove that negligent conduct by the employer was the cause of the
15-29 occupational disease.
15-30 (c) May enter into a contract with any person to assist in the collection
15-31 of any liability of an uninsured employer.
15-32 (d) In lieu of a civil action, may enter into an agreement or settlement
15-33 regarding the collection of any liability of an uninsured employer.
15-34 7. The division shall:
15-35 (a) Determine whether the employer was insured within 30 days after
15-36 receiving the claim from the employee.
15-37 (b) Assign the claim to the third-party administrator or insurer
15-38 designated pursuant to subsection 1 for administration and payment of
15-39 compensation.
15-40 Upon determining whether the claim is accepted or denied, the designated
15-41 third-party administrator or insurer shall notify the injured employee, the
15-42 named employer and the division of its determination.
15-43 8. Upon demonstration of the:
15-44 (a) Costs incurred by the designated third-party administrator or insurer
15-45 to administer the claim or pay compensation to the injured employee; or
15-46 (b) Amount that the designated third-party administrator or insurer will
15-47 pay for administrative expenses or compensation to the injured employee
15-48 and that such amounts are justified by the circumstances of the
15-49 claim,
16-1 the division shall authorize payment from the uninsured employers’ claim
16-2 fund.
16-3 9. Any party aggrieved by a determination regarding the
16-4 administration of an assigned claim or a determination made by the
16-5 division or by the designated third-party administrator or insurer regarding
16-6 any claim made pursuant to this section may appeal that determination
16-7 within 60 days after the determination is rendered to the hearings division
16-8 of the department of administration in the manner provided by NRS
16-9 616C.305 and 616C.315 to 616C.385, inclusive.
16-10 10. All insurers shall bear a proportionate amount of a claim made
16-11 pursuant to this chapter, and are entitled to a proportionate amount of any
16-12 collection made pursuant to this section as an offset against future
16-13 liabilities.
16-14 11. An uninsured employer is liable for the interest on any amount
16-15 paid on his claims from the uninsured employers’ claim fund. The interest
16-16 must be calculated at a rate equal to the prime rate at the largest bank in
16-17 Nevada, as ascertained by the commissioner of financial institutions, on
16-18 January 1 or July 1, as the case may be, immediately preceding the date of
16-19 the claim, plus 3 percent, compounded monthly, from the date the claim is
16-20 paid from the fund until payment is received by the division from the
16-21 employer.
16-22 12. Attorney’s fees recoverable by the division pursuant to this section
16-23 must be:
16-24 (a) If a private attorney is retained by the division, paid at the usual and
16-25 customary rate for that attorney.
16-26 (b) If the attorney is an employee of the division, paid at the rate
16-27 established by regulations adopted by the division.
16-28 Any money collected must be deposited to the uninsured employers’ claim
16-29 fund.
16-30 13. In addition to any other liabilities provided for in this section, the
16-31 administrator may impose an administrative fine of not more than $10,000
16-32 against an employer if the employer fails to provide mandatory coverage
16-33 required by the provisions of this chapter.
16-34 Sec. 24. If a different rate of interest has been established pursuant to
16-35 an express written contract between an administrator, insurer, carrier,
16-36 corporation or health maintenance organization and a provider of health
16-37 care, the amendatory provisions of sections 1.5, 3, 5, 7, 10, 11.3, 15 and 18
16-38 of this act, relating to the amount of interest that accrues if an approved
16-39 claim is not timely paid, apply only to contracts between the administrator,
16-40 insurer, carrier, corporation or health maintenance organization and the
16-41 provider of health care that are entered into or renewed on or after
16-42 October 1, 2001.
16-43 Sec. 25. 1. This section, sections 1 to 11.7, inclusive, and 13 to 24,
16-44 inclusive, of this act become effective on October 1, 2001.
16-45 2. Section 12 of this act becomes effective at 12:01 a.m. on October 1,
16-46 2001.
16-47 H