requires two-thirds majority vote (§ 3)                                                                                                                 

                                                                                                  

 

Senate Bill No. 320–Senator Shaffer (by request)

 

March 17, 2003

____________

 

Referred to Committee on Commerce and Labor

 

SUMMARY—Makes various changes to provisions governing industrial insurance. (BDR 53‑600)

 

FISCAL NOTE:    Effect on Local Government: No.

                             Effect on the State: Yes.

 

~

 

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

 

AN ACT relating to industrial insurance; establishing a system of external review for certain matters relating to industrial insurance; providing for the regulation and certification of certain external review organizations; providing for the payment of certain regulatory fees by external review organizations; authorizing an organization for managed care to charge an administrative fee to providers of health care under certain circumstances; requiring the adoption of certain medical standards for evaluating permanent impairments to injured employees; revising various provisions relating to medical treatment of injured employees; revising various provisions relating to the processing of claims and the payment of compensation to injured employees; revising certain procedures and establishing certain requirements relating to the adjudication of contested claims; 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. Chapter 616A of NRS is hereby amended by

1-2  adding thereto the provisions set forth as sections 2 and 3 of this act.

1-3  Sec. 2.  “External review organization” means an

1-4  organization which has been issued a certificate pursuant to

1-5  section 3 of this act that authorizes the organization to conduct

2-1  external reviews for the purposes of chapters 616A to 616D,

2-2  inclusive, of NRS.

2-3  Sec. 3.  1.  If the Administrator determines that an external

2-4  review organization is qualified to conduct external reviews for the

2-5  purposes of chapters 616A to 616D, inclusive, of NRS, the

2-6  Administrator shall issue a certificate to the external review

2-7  organization that authorizes the organization to conduct such

2-8  external reviews in accordance with the provisions of section 6 of

2-9  this act and the regulations adopted by the Administrator.

2-10      2.  The Administrator shall adopt regulations setting forth the

2-11  procedures that an external review organization must follow to be

2-12  issued a certificate to conduct external reviews. The regulations

2-13  must include, without limitation, provisions setting forth:

2-14      (a) The manner in which an external review organization may

2-15  apply for a certificate and the requirements for the issuance and

2-16  renewal of the certificate pursuant to this section;

2-17      (b) The grounds for which the Administrator may refuse to

2-18  issue, suspend, revoke or refuse to renew a certificate issued

2-19  pursuant to this section;

2-20      (c) The manner and circumstances under which an external

2-21  review organization is required to conduct its business; and

2-22      (d) A fee for issuing or renewing a certificate of an external

2-23  review organization pursuant to this section. The fee must not

2-24  exceed the cost of issuing or renewing the certificate.

2-25      3.  A certificate issued pursuant to this section expires 1 year

2-26  after it is issued and may be renewed in accordance with

2-27  regulations adopted by the Administrator.

2-28      4.  Before the Administrator may issue a certificate to an

2-29  external review organization, the external review organization

2-30  must:

2-31      (a) Demonstrate to the satisfaction of the Administrator that it

2-32  is able to carry out, in a timely manner, the duties of an external

2-33  review organization as set forth in section 6 of this act and the

2-34  regulations adopted by the Administrator. The demonstration must

2-35  include, without limitation, proof that the external review

2-36  organization employs, contracts with or otherwise retains only

2-37  persons who are qualified because of their education, training,

2-38  professional licensing and experience to perform the duties

2-39  assigned to those persons; and

2-40      (b) Provide assurances satisfactory to the Administrator that

2-41  the external review organization will:

2-42          (1) Conduct external reviews in accordance with the

2-43  provisions of section 6 of this act and the regulations adopted by

2-44  the Administrator;

3-1       (2) Render its decisions in a clear, consistent, thorough and

3-2  timely manner; and

3-3       (3) Avoid conflicts of interest.

3-4  5.  For the purposes of this section, an external review

3-5  organization has a conflict of interest if the external review

3-6  organization or any employee, agent or contractor of the external

3-7  review organization who conducts an external review has a

3-8  professional, familial or financial interest of a material nature

3-9  with respect to any person who has a substantial interest in the

3-10  outcome of the external review, including, without limitation:

3-11      (a) The claimant;

3-12      (b) The employer; or

3-13      (c) The insurer or any officer, director or management

3-14  employee of the insurer.

3-15      6.  The Administrator shall not issue a certificate to an

3-16  external review organization that is affiliated with:

3-17      (a) An organization for managed care;

3-18      (b) An insurer; or

3-19      (c) A national, state or local trade association.

3-20      7.  An external review organization which is certified or

3-21  accredited by an accrediting body that is nationally recognized

3-22  shall be deemed to have satisfied all the conditions and

3-23  qualifications required for the external review organization to be

3-24  issued a certificate pursuant to this section.

3-25      Sec. 4.  NRS 616A.025 is hereby amended to read as follows:

3-26      616A.025  As used in chapters 616A to 616D, inclusive, of

3-27  NRS, unless the context otherwise requires, the words and terms

3-28  defined in NRS 616A.030 to 616A.360, inclusive, and section 2 of

3-29  this act have the meanings ascribed to them in those sections.

3-30      Sec. 5.  NRS 616B.5285 is hereby amended to read as follows:

3-31      616B.5285  1.  In any contract between an organization for

3-32  managed care and a provider of health care, the organization for

3-33  managed care may charge the provider of health care an

3-34  administrative fee of not more than $200 per year for

3-35  administrative costs and services associated with the contract,

3-36  including, without limitation:

3-37      (a) Investigating, reviewing, confirming or certifying the

3-38  credentials of the provider of health care; and

3-39      (b) Providing education and support to the provider of health

3-40  care.

3-41      2.  An organization for managed care shall not terminate a

3-42  contract with, demote, refuse to contract with or refuse to

3-43  compensate a provider of health care solely because the provider, in

3-44  good faith:

4-1  [1.] (a) Advocates in private or in public on behalf of an injured

4-2  employee;

4-3  [2.] (b) Assists an injured employee in seeking reconsideration

4-4  of a determination by the organization for managed care to deny

4-5  coverage for a medical or health care service; or

4-6  [3.] (c) Reports a violation of law to an appropriate authority.

4-7  Sec. 6.  Chapter 616C of NRS is hereby amended by adding

4-8  thereto a new section to read as follows:

4-9  1.  Not later than 5 days after the date that an appeals officer

4-10  submits a matter to an external review organization pursuant to

4-11  NRS 616C.360, the external review organization shall:

4-12      (a) Review the documents and materials submitted for the

4-13  external review; and

4-14      (b) Notify the injured employee, his employer and the insurer

4-15  whether the external review organization needs any additional

4-16  information to conduct the external review.

4-17      2.  The external review organization shall render a decision

4-18  on the matter not later than 15 days after the date that it receives

4-19  all information that is necessary to conduct the external review.

4-20      3.  In conducting the external review, the external review

4-21  organization shall consider, without limitation:

4-22      (a) The medical records of the insured;

4-23      (b) Any recommendations of the physician of the insured; and

4-24      (c) Any other information approved by the Administrator for

4-25  consideration by an external review organization.

4-26      4.  In its decision, the external review organization shall

4-27  specify the reasons for its decision. The external review

4-28  organization shall submit a copy of its decision to:

4-29      (a) The injured employee;

4-30      (b) The employer;

4-31      (c) The insurer; and

4-32      (d) The appeals officer.

4-33      5.  The Administrator shall adopt regulations to govern the

4-34  process of external review and to carry out the provisions of this

4-35  section.

4-36      Sec. 7.  NRS 616C.090 is hereby amended to read as follows:

4-37      616C.090  1.  The Administrator shall establish a panel of

4-38  physicians and chiropractors who have demonstrated special

4-39  competence and interest in industrial health to treat injured

4-40  employees under chapters 616A to 616D, inclusive, or chapter 617

4-41  of NRS. Every employer whose insurer has not entered into a

4-42  contract with an organization for managed care or with providers of

4-43  health care services pursuant to NRS 616B.527 shall maintain a list

4-44  of those physicians and chiropractors on the panel who are

4-45  reasonably accessible to his employees.

5-1  2.  An injured employee whose employer’s insurer has not

5-2  entered into a contract with an organization for managed care or

5-3  with providers of health care services pursuant to NRS 616B.527

5-4  may choose his treating physician or chiropractor from the panel of

5-5  physicians and chiropractors. If the injured employee is not satisfied

5-6  with the first physician or chiropractor he so chooses, he may make

5-7  an alternative choice of physician or chiropractor from the panel if

5-8  the choice is made within 90 days after his injury. The insurer shall

5-9  notify the first physician or chiropractor in writing. The notice must

5-10  be postmarked within 3 working days after the insurer receives

5-11  knowledge of the change. The first physician or chiropractor must

5-12  be reimbursed only for the services he rendered to the injured

5-13  employee up to and including the date of notification. [Except as

5-14  otherwise provided in this subsection, any] Any further change is

5-15  subject to the approval of the insurer, which must be granted or

5-16  denied within 10 days after a written request for such a change is

5-17  received from the injured employee. If no action is taken on the

5-18  request within 10 days, the request shall be deemed granted. Any

5-19  request for a change of physician or chiropractor must include the

5-20  name of the new physician or chiropractor chosen by the injured

5-21  employee. [If the treating physician or chiropractor refers the

5-22  injured employee to a specialist for treatment, the treating physician

5-23  or chiropractor shall provide to the injured employee a list that

5-24  includes the name of each physician or chiropractor with that

5-25  specialization who is on the panel. After receiving the list, the

5-26  injured employee shall, at the time the referral is made, select a

5-27  physician or chiropractor from the list.]

5-28      3.  An injured employee whose employer’s insurer has entered

5-29  into a contract with an organization for managed care or with

5-30  providers of health care services pursuant to NRS 616B.527 must

5-31  choose his treating physician or chiropractor pursuant to the terms

5-32  of that contract. If the injured employee is not satisfied with the first

5-33  physician or chiropractor he so chooses, he may make an alternative

5-34  choice of physician or chiropractor pursuant to the terms of the

5-35  contract if the choice is made within 90 days after his injury. If the

5-36  injured employee, after choosing his treating physician or

5-37  chiropractor, moves to a county which is not served by the

5-38  organization for managed care or providers of health care services

5-39  named in the contract and the insurer determines that it is

5-40  impractical for the injured employee to continue treatment with the

5-41  physician or chiropractor, the injured employee must choose a

5-42  treating physician or chiropractor who has agreed to the terms of

5-43  that contract unless the insurer authorizes the injured employee to

5-44  choose another physician or chiropractor. [If the treating physician

5-45  or chiropractor refers the injured employee to a specialist for

6-1  treatment, the treating physician or chiropractor shall provide to the

6-2  injured employee a list that includes the name of each physician or

6-3  chiropractor with that specialization who is available pursuant to the

6-4  terms of the contract with the organization for managed care or with

6-5  providers of health care services pursuant to NRS 616B.527, as

6-6  appropriate. After receiving the list, the injured employee shall,

6-7  at the time the referral is made, select a physician or chiropractor

6-8  from the list. If the employee fails to select a physician or

6-9  chiropractor, the insurer may select a physician or chiropractor with

6-10  that specialization. If a physician or chiropractor with that

6-11  specialization is not available pursuant to the terms of the contract,

6-12  the organization for managed care or the provider of health care

6-13  services may select a physician or chiropractor with that

6-14  specialization.]

6-15      4.  Except when emergency medical care is required and except

6-16  as otherwise provided in NRS 616C.055, the insurer is not

6-17  responsible for any charges for medical treatment or other accident

6-18  benefits furnished or ordered by any physician, chiropractor or other

6-19  person selected by the injured employee in disregard of the

6-20  provisions of this section or for any compensation for any

6-21  aggravation of the injured employee’s injury attributable to

6-22  improper treatments by such physician, chiropractor or other person.

6-23      5.  The Administrator may order necessary changes in a panel

6-24  of physicians and chiropractors and shall suspend or remove any

6-25  physician or chiropractor from a panel for good cause shown.

6-26      6.  An injured employee may receive treatment by more than

6-27  one physician or chiropractor if the insurer provides written

6-28  authorization for such treatment.

6-29      7.  The Administrator shall design a form that notifies injured

6-30  employees of their right pursuant to subsections 2 and 3 to select an

6-31  alternative treating physician or chiropractor and make the form

6-32  available to insurers for distribution pursuant to subsection 2 of

6-33  NRS 616C.050.

6-34      Sec. 8.  NRS 616C.110 is hereby amended to read as follows:

6-35      616C.110  1.  For the purposes of NRS 616B.557, 616B.578,

6-36  616B.587, 616C.490 and 617.459, the Division shall adopt

6-37  regulations incorporating the American Medical Association’s

6-38  Guides to the Evaluation of Permanent Impairment , 4th Edition,

6-39  3rd Printing, by reference . [and] The Division may amend those

6-40  regulations from time to time as it deems necessary[. In adopting] ,

6-41  except that the amendments to those regulations:

6-42      (a) Must be consistent with the American Medical

6-43  Association’s Guides to the Evaluation of Permanent Impairment,

6-44  [the Division shall consider the edition most recently published by]

6-45  4th Edition, 3rd Printing; and

7-1  (b) Must not incorporate any contradictory matter from any

7-2  other edition or printing of the American Medical [Association.]

7-3  Association’s Guides to the Evaluation of Permanent Impairment.

7-4  2.  If the American Medical Association’s Guides to the

7-5  Evaluation of Permanent Impairment [adopted by the Division

7-6  contain] , 4th Edition, 3rd Printing, contains more than one method

7-7  of determining the rating of an impairment, the Administrator shall

7-8  designate by regulation the method from that edition and printing

7-9  which must be used to rate an impairment pursuant to

7-10  NRS 616C.490.

7-11      Sec. 9.  NRS 616C.175 is hereby amended to read as follows:

7-12      616C.175  1.  The resulting condition of an employee who:

7-13      (a) Has a preexisting condition from a cause or origin that did

7-14  not arise out of or in the course of his current or past employment;

7-15  and

7-16      (b) Subsequently sustains an injury by accident arising out of

7-17  and in the course of his employment which aggravates, precipitates

7-18  or accelerates his preexisting condition,

7-19  shall be deemed to be an injury by accident that is compensable

7-20  pursuant to the provisions of chapters 616A to 616D, inclusive, of

7-21  NRS, unless the insurer can prove by a preponderance of the

7-22  evidence that the subsequent injury is not [a substantial

7-23  contributing] the primary cause of the resulting condition.

7-24      2.  The resulting condition of an employee who:

7-25      (a) Sustains an injury by accident arising out of and in the

7-26  course of his employment; and

7-27      (b) Subsequently aggravates, precipitates or accelerates the

7-28  injury in a manner that does not arise out of and in the course of his

7-29  employment,

7-30  shall be deemed to be an injury by accident that is compensable

7-31  pursuant to the provisions of chapters 616A to 616D, inclusive, of

7-32  NRS, unless the insurer can prove by a preponderance of the

7-33  evidence that the injury described in paragraph (a) is not [a

7-34  substantial contributing] the primary cause of the resulting

7-35  condition.

7-36      Sec. 10.  NRS 616C.245 is hereby amended to read as follows:

7-37      616C.245  1.  Every injured employee within the provisions of

7-38  chapters 616A to 616D, inclusive, of NRS is entitled to receive

7-39  promptly such accident benefits as may reasonably be required at

7-40  the time of the injury and within 6 months thereafter. Such benefits

7-41  may be further extended for additional periods as may be required.

7-42      2.  An injured employee is entitled to receive as an accident

7-43  benefit a motor vehicle that is modified to allow the employee to

7-44  operate the vehicle safely if:

8-1  (a) As a result of an injury arising out of and in the course of his

8-2  employment, he is quadriplegic, paraplegic or has had a part of his

8-3  body amputated; and

8-4  (b) He cannot be fitted with a prosthetic device which allows

8-5  him to operate a motor vehicle safely.

8-6  3.  If an injured employee is entitled to receive a motor vehicle

8-7  pursuant to subsection 2, a motor vehicle must be modified to allow

8-8  the employee to operate it safely in the following order of

8-9  preference:

8-10      (a) A motor vehicle owned by the injured employee must be so

8-11  modified if the insurer or employer providing accident benefits

8-12  determines that it is reasonably feasible to do so.

8-13      (b) A used motor vehicle must be so modified if the insurer or

8-14  employer providing accident benefits determines that it is

8-15  reasonably feasible to do so.

8-16      (c) A new motor vehicle must be so modified.

8-17      4.  The Administrator shall adopt regulations establishing a

8-18  maximum benefit to be paid under the provisions of this section.

8-19      Sec. 11.  NRS 616C.315 is hereby amended to read as follows:

8-20      616C.315  1.  Any person who is subject to the jurisdiction of

8-21  the hearing officers pursuant to chapters 616A to 616D, inclusive, or

8-22  chapter 617 of NRS may request a hearing before a hearing officer

8-23  of any matter within the hearing officer’s authority. The insurer

8-24  shall provide, without cost, the forms necessary to request a hearing

8-25  to any person who requests them.

8-26      2.  A request for a hearing must be dismissed unless the

8-27  request for a hearing includes:

8-28      (a) The name and last known mailing address of:

8-29          (1) The claimant;

8-30          (2) The employer; and

8-31          (3) The insurer;

8-32      (b) The number of the claim; and

8-33      (c) A copy of the letter of determination being appealed, or if

8-34  such a copy is unavailable, the date of the determination and the

8-35  issues stated in the determination.

8-36      3.  Except as otherwise provided in NRS 616B.772, 616B.775,

8-37  616B.787 and 616C.305, a person who is aggrieved by:

8-38      (a) A written determination of an insurer; or

8-39      (b) The failure of an insurer to respond within 30 days to a

8-40  written request mailed to the insurer by the person who is

8-41  aggrieved,

8-42  may appeal from the determination or failure to respond by filing a

8-43  request for a hearing before a hearing officer. Such a request must

8-44  be filed within 70 days after the date on which the notice of the

8-45  insurer’s determination was mailed by the insurer or the unanswered

9-1  written request was mailed to the insurer, as applicable. The failure

9-2  of an insurer to respond to a written request for a determination

9-3  within 30 days after receipt of such a request shall be deemed by the

9-4  hearing officer to be a denial of the request.

9-5  [3.] 4.  Failure to file a request for a hearing within the period

9-6  specified in subsection [2] 3 may be excused if the person aggrieved

9-7  shows by a preponderance of the evidence that he did not receive

9-8  the notice of the determination and the forms necessary to request a

9-9  hearing. The claimant or employer shall notify the insurer of a

9-10  change of address.

9-11      [4.] 5.  The hearing before the hearing officer must be

9-12  conducted as expeditiously and informally as is practicable.

9-13      [5.] 6.  The parties to a contested claim may, if the claimant is

9-14  represented by legal counsel, agree to forego a hearing before a

9-15  hearing officer and submit the contested claim directly to an appeals

9-16  officer.

9-17      Sec. 12.  NRS 616C.345 is hereby amended to read as follows:

9-18      616C.345  1.  Any party aggrieved by a decision of the

9-19  hearing officer relating to a claim for compensation may appeal

9-20  from the decision by filing a notice of appeal with an appeals officer

9-21  within 30 days after the date of the decision.

9-22      2.  A request for a hearing must be dismissed unless the

9-23  request for a hearing includes:

9-24      (a) The name and last known mailing address of:

9-25          (1) The claimant;

9-26          (2) The employer; and

9-27          (3) The insurer;

9-28      (b) The number of the claim; and

9-29      (c) A copy of the letter of determination being appealed, or if

9-30  such a copy is unavailable, the date of the determination and the

9-31  issues stated in the determination.

9-32      3.  If a dispute is required to be submitted to a procedure for

9-33  resolving complaints pursuant to NRS 616C.305 and:

9-34      (a) A final determination was rendered pursuant to that

9-35  procedure; or

9-36      (b) The dispute was not resolved pursuant to that procedure

9-37  within 14 days after it was submitted,

9-38  any party to the dispute may file a notice of appeal within 70 days

9-39  after the date on which the final determination was mailed to the

9-40  employee, or his dependent, or the unanswered request for

9-41  resolution was submitted. Failure to render a written determination

9-42  within 30 days after receipt of such a request shall be deemed by the

9-43  appeals officer to be a denial of the request.

9-44      [3.] 4. Except as otherwise provided in NRS 616C.380, the

9-45  filing of a notice of appeal does not automatically stay the

10-1  enforcement of the decision of a hearing officer or a determination

10-2  rendered pursuant to NRS 616C.305. The appeals officer may order

10-3  a stay, when appropriate, upon the application of a party. If such an

10-4  application is submitted, the decision is automatically stayed until a

10-5  determination is made concerning the application. A determination

10-6  on the application must be made within 30 days after the filing of

10-7  the application. If a stay is not granted by the officer after reviewing

10-8  the application, the decision must be complied with within 10 days

10-9  after the date of the refusal to grant a stay.

10-10     [4.] 5. Except as otherwise provided in this subsection, the

10-11  appeals officer shall, within 10 days after receiving a notice of

10-12  appeal pursuant to this section or a contested claim pursuant to

10-13  subsection [5] 6 of NRS 616C.315, schedule a hearing on the merits

10-14  of the appeal or contested claim for a date and time within 90 days

10-15  after his receipt of the notice and give notice by mail or by personal

10-16  service to all parties to the matter and their attorneys or agents at

10-17  least 30 days before the date and time scheduled. A request to

10-18  schedule the hearing for a date and time which is:

10-19     (a) Within 60 days after the receipt of the notice of appeal or

10-20  contested claim; or

10-21     (b) More than 90 days after the receipt of the notice or

10-22  claim,

10-23  may be submitted to the appeals officer only if all parties to the

10-24  appeal or contested claim agree to the request.

10-25     [5.] 6. An appeal or contested claim may be continued upon

10-26  written stipulation of all parties, or upon good cause shown.

10-27     [6.] 7. Failure to file a notice of appeal within the period

10-28  specified in subsection 1 or [2] 3 may be excused if the party

10-29  aggrieved shows by a preponderance of the evidence that he did not

10-30  receive the notice of the determination and the forms necessary to

10-31  appeal the determination. The claimant, employer or insurer shall

10-32  notify the hearing officer of a change of address.

10-33     Sec. 13.  NRS 616C.360 is hereby amended to read as follows:

10-34     616C.360  1.  A stenographic or electronic record must be kept

10-35  of the hearing before the appeals officer and the rules of evidence

10-36  applicable to contested cases under chapter 233B of NRS apply to

10-37  the hearing.

10-38     2.  The appeals officer must hear any matter raised before him

10-39  on its merits, including new evidence bearing on the matter.

10-40     3.  If necessary to resolve a medical question concerning an

10-41  injured employee’s condition or to determine the necessity of

10-42  treatment for which authorization for payment has been denied, the

10-43  appeals officer [may refer the employee to a physician or

10-44  chiropractor of his choice who has demonstrated special competence

10-45  to treat the particular medical condition of the employee. If the

11-1  medical question concerns the rating of a permanent disability, the

11-2  appeals officer may refer the employee to a rating physician or

11-3  chiropractor. The rating physician or chiropractor must be selected

11-4  in rotation from the list of qualified physicians or chiropractors

11-5  maintained by the Administrator pursuant to subsection 2 of NRS

11-6  616C.490, unless the insurer and the injured employee otherwise

11-7  agree to a rating physician or chiropractor.] shall submit the matter

11-8  to an external review organization in accordance with section 6 of

11-9  this act and the regulations adopted by the Administrator. The

11-10  insurer shall pay the costs of [any examination requested by] the

11-11  external review. After the external review organization renders its

11-12  decision on the matter, the decision is binding on the appeals

11-13  officer.

11-14     4.  If an injured employee has requested payment for the cost of

11-15  obtaining a second determination of his percentage of disability

11-16  pursuant to NRS 616C.100, the appeals officer shall decide whether

11-17  the determination of the higher percentage of disability made

11-18  pursuant to NRS 616C.100 is appropriate and, if so, may order the

11-19  insurer to pay to the employee an amount equal to the maximum

11-20  allowable fee established by the Administrator pursuant to NRS

11-21  616C.260 for the type of service performed, or the usual fee of that

11-22  physician or chiropractor for such service, whichever is less.

11-23     5.  The appeals officer shall order an insurer, organization for

11-24  managed care or employer who provides accident benefits for

11-25  injured employees pursuant to NRS 616C.265 to pay the charges of

11-26  a provider of health care if the conditions of NRS 616C.138 are

11-27  satisfied.

11-28     6.  Any party to the appeal or the appeals officer may order a

11-29  transcript of the record of the hearing at any time before the seventh

11-30  day after the hearing. The transcript must be filed within 30 days

11-31  after the date of the order unless the appeals officer otherwise

11-32  orders.

11-33     7.  The appeals officer shall render his decision:

11-34     (a) If a transcript is ordered within 7 days after the hearing,

11-35  within 30 days after the transcript is filed; or

11-36     (b) If a transcript has not been ordered, within 30 days after the

11-37  date of the hearing.

11-38     8.  The appeals officer may affirm, modify or reverse any

11-39  decision made by the hearing officer and issue any necessary and

11-40  proper order to give effect to his decision.

11-41     Sec. 14.  NRS 616C.390 is hereby amended to read as follows:

11-42     616C.390  1.  If an application to reopen a claim to increase or

11-43  rearrange compensation is made in writing more than 1 year after

11-44  the date on which the claim was closed, the insurer shall reopen the

11-45  claim if:

12-1      (a) A change of circumstances warrants an increase or

12-2  rearrangement of compensation during the life of the claimant;

12-3      (b) The primary cause of the change of circumstances is the

12-4  injury for which the claim was originally made; and

12-5      (c) The application is accompanied by the certificate of a

12-6  physician or a chiropractor showing a change of circumstances

12-7  which would warrant an increase or rearrangement of compensation.

12-8      2.  After a claim has been closed, the insurer, upon receiving an

12-9  application and for good cause shown, may authorize the reopening

12-10  of the claim for medical investigation only. The application must be

12-11  accompanied by a written request for treatment from the physician

12-12  or chiropractor treating the claimant, certifying that the treatment is

12-13  indicated by a change in circumstances and is related to the

12-14  industrial injury sustained by the claimant.

12-15     3.  If a claimant applies for a claim to be reopened pursuant to

12-16  subsection 1 or 2 and a final determination denying the reopening is

12-17  issued, the claimant shall not reapply to reopen the claim until at

12-18  least 1 year after the date on which the final determination is issued.

12-19     4.  Except as otherwise provided in subsection 5, if an

12-20  application to reopen a claim is made in writing within 1 year after

12-21  the date on which the claim was closed, the insurer shall reopen the

12-22  claim only if:

12-23     (a) The application is supported by medical evidence

12-24  demonstrating an objective change in the medical condition of the

12-25  claimant; and

12-26     (b) There is clear and convincing evidence that the primary

12-27  cause of the change of circumstances is the injury for which the

12-28  claim was originally made.

12-29     5.  An application to reopen a claim must be made in writing

12-30  within 1 year after the date on which the claim was closed if:

12-31     (a) The claimant was not off work as a result of the injury; and

12-32     (b) The claimant did not receive benefits for a permanent partial

12-33  disability.

12-34  If an application to reopen a claim to increase or rearrange

12-35  compensation is made pursuant to this subsection, the insurer shall

12-36  reopen the claim if the requirements set forth in paragraphs (a), (b)

12-37  and (c) of subsection 1 are met.

12-38     6.  If an employee’s claim is reopened pursuant to this section,

12-39  he is not entitled to vocational rehabilitation services or benefits for

12-40  a temporary total disability if, before his claim was reopened, he:

12-41     (a) Retired; or

12-42     (b) Otherwise voluntarily removed himself from the

12-43  workforce,

12-44  for reasons unrelated to the injury for which the claim was originally

12-45  made.

13-1      7.  One year after the date on which the claim was closed, an

13-2  insurer may dispose of the file of a claim authorized to be reopened

13-3  pursuant to subsection 5, unless an application to reopen the claim

13-4  has been filed pursuant to that subsection.

13-5      8.  An increase or rearrangement of compensation is not

13-6  effective before an application for reopening a claim is made unless

13-7  good cause is shown. The insurer shall, upon good cause shown,

13-8  allow the cost of emergency treatment the necessity for which has

13-9  been certified by a physician or a chiropractor.

13-10     9.  A claim that closes pursuant to subsection 2 of NRS

13-11  616C.235 and is not appealed or is unsuccessfully appealed pursuant

13-12  to the provisions of NRS 616C.305 and 616C.315 to 616C.385,

13-13  inclusive, may not be reopened pursuant to this section.

13-14     [10.  The provisions of this section apply to any claim for which

13-15  an application to reopen the claim or to increase or rearrange

13-16  compensation is made pursuant to this section, regardless of the date

13-17  of the injury or accident to the claimant. If a claim is reopened

13-18  pursuant to this section, the amount of any compensation or benefits

13-19  provided must be determined in accordance with the provisions of

13-20  NRS 616C.425.]

13-21     Sec. 15.  NRS 695C.125 is hereby amended to read as follows:

13-22     695C.125  1.  A health maintenance organization shall not

13-23  charge a provider of health care a fee to include the name of the

13-24  provider on a list of providers of health care given by the health

13-25  maintenance organization to its enrollees.

13-26     2.  The provisions of this section do not apply to an

13-27  administrative fee charged to a provider of health care pursuant to

13-28  NRS 616B.5285.

13-29     Sec. 16.  NRS 695G.270 is hereby amended to read as follows:

13-30     695G.270  1.  A managed care organization that establishes a

13-31  panel of providers of health care for the purpose of offering health

13-32  care services pursuant to chapter 689A, 689B, 689C, 695A, 695B or

13-33  695C of NRS shall not charge a provider of health care a fee to

13-34  include the name of the provider on the panel of providers of health

13-35  care.

13-36     2.  The provisions of this section do not apply to an

13-37  administrative fee charged to a provider of health care pursuant to

13-38  NRS 616B.5285.

13-39     Sec. 17.  1.  Notwithstanding the amendatory provisions of

13-40  this act, an appeals officer shall not submit a matter for external

13-41  review pursuant to NRS 616C.360, as amended by this act, until the

13-42  Administrator has issued a certificate pursuant to section 3 of this

13-43  act to at least one external review organization that is qualified to

13-44  conduct an external review of the matter.

14-1      2.  As used in this section, “Administrator” means the

14-2  Administrator of the Division of Industrial Relations of the

14-3  Department of Business and Industry.

14-4      Sec. 18.  This act becomes effective upon passage and approval

14-5  for the purpose of adopting regulations, and on October 1, 2003, for

14-6  all other purposes.

 

14-7  H