Nev. Rev. Stat. § 695G.010
Definitions
As used in this chapter, unless the context otherwise requires, the words and terms defined in NRS 695G.012 to 695G.085, inclusive, have the meanings ascribed to them in those sections.
Nevada Revised Statutes Chapter 695G — Managed Care
Nevada · statute · Nev. Rev. Stat. ch. 695G · 99 active provisions
Nev. Rev. Stat. § 695G.012
“Adverse determination” defined
“Adverse determination” means a determination by a health carrier or utilization review organization that an admission, availability of care, continued stay or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier’s requirements…
Nev. Rev. Stat. § 695G.014
“Authorized representative” defined
“Authorized representative” means: 1. A person to whom a covered person has given express written consent to represent the covered person in an external review of an adverse determination conducted pursuant to NRS 695G.241 to 695G.310, inclusive; 2. A person authorized by law to provide substituted consent for a covere…
Nev. Rev. Stat. § 695G.015
“Benefits” defined
“Benefits” means those health care services to which a covered person is entitled under the terms of a health benefit plan.
Nev. Rev. Stat. § 695G.016
“Clinical peer” defined
“Clinical peer” means: 1. A physician who is: (a) Engaged in the practice of medicine; and (b) Certified or is eligible for certification by a member board of the American Board of Medical Specialties in the same or similar area of practice as is the health care service that is the subject of a final adverse determinat…
Nev. Rev. Stat. § 695G.017
“Covered person” defined
“Covered person” means a policyholder, subscriber, enrollee or other person participating in a health benefit plan.
Nev. Rev. Stat. § 695G.019
“Health benefit plan” defined
“Health benefit plan” means a policy, contract, certificate or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.
Nev. Rev. Stat. § 695G.020
“Health care plan” defined
“Health care plan” means a policy, contract, certificate or agreement offered or issued by a managed care organization to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.
Nev. Rev. Stat. § 695G.022
“Health care services” defined
“Health care services” means services for the diagnosis, prevention, treatment, care or relief of a health condition, illness, injury or disease.
Nev. Rev. Stat. § 695G.024
“Health carrier” defined
“Health carrier” means an entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the Commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services, including, without limitation, a sicknes…
Nev. Rev. Stat. § 695G.026
“Independent review organization” defined
“Independent review organization” means an entity that: 1. Conducts an independent external review of an adverse determination; and 2. Is certified by the Commissioner in accordance with NRS 683A.3715 and 683A.372.
Nev. Rev. Stat. § 695G.030
“Insured” defined
“Insured” means a person who receives benefits under a health care plan.
Nev. Rev. Stat. § 695G.040
“Managed care” defined
“Managed care” means a system for delivering health care services that encourages the efficient use of health care services by using employed or independently contracted providers of health care and by using various techniques which may include, without limitation: 1. Managing the health care services of an insured who…
Nev. Rev. Stat. § 695G.050
“Managed care organization” defined
“Managed care organization” means any insurer or organization authorized pursuant to this title to conduct business in this State that provides or arranges for the provision of health care services through managed care.
Nev. Rev. Stat. § 695G.053
“Medical or scientific evidence” defined
“Medical or scientific evidence” means evidence found in the following sources: 1. Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts…
Nev. Rev. Stat. § 695G.055
“Medically necessary” defined
“Medically necessary” means health care services or products that a prudent physician would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and: 1. Provided in accordance with generally accepted standards of medical practice; 2. Clinically ap…
Nev. Rev. Stat. § 695G.060
“Primary care physician” defined
“Primary care physician” means a physician or group of physicians who: 1. Provides initial and primary health care services to an insured; 2. Maintains the continuity of care for the insured; and 3. May refer the insured to a specialized provider of health care.
Nev. Rev. Stat. § 695G.070
“Provider of health care” defined
“Provider of health care” means: 1. A physician or other health care practitioner who is licensed or otherwise authorized in this State to furnish any health care service; and 2. An institution providing health care services or other setting in which health care services are provided, including, without limitation, a h…
Nev. Rev. Stat. § 695G.080
“Utilization review” defined
1. “Utilization review” means the various methods that may be used to review the amount and appropriateness of the provision of a specific health care service. 2. The term does not include an external review of an adverse determination conducted pursuant to NRS 695G.241 to 695G.310, inclusive.
Nev. Rev. Stat. § 695G.085
“Utilization review organization” defined
“Utilization review organization” means an entity designated by a health carrier to conduct utilization reviews.
Nev. Rev. Stat. § 695G.090
Applicability of chapter and other provisions
1. Except as otherwise provided in subsection 3, the provisions of this chapter apply to each organization and insurer that operates as a managed care organization and may include, without limitation, an insurer that issues a policy of health insurance, an insurer that issues a policy of individual or group health insu…
Nev. Rev. Stat. § 695G.095
Offering policy of health insurance for purposes of establishing health savings account
A managed care organization may, subject to regulation by the Commissioner, offer a policy of health insurance that has a high deductible and is in compliance with 26 U.S.C. § 223 for the purposes of establishing a health savings account.
Nev. Rev. Stat. § 695G.100
Documents filed with Commissioner treated as public record; exception
Any document required to be filed with the Commissioner pursuant to this chapter, other than medical records and other information relating to a specific insured, must be treated as a public record.
Nev. Rev. Stat. § 695G.110
Medical director required to be physician licensed in this State
Each managed care organization shall employ or contract with a physician who is licensed to practice medicine in the State of Nevada pursuant to chapter 630 or 633 of NRS to serve as its medical director.
Nev. Rev. Stat. § 695G.120
Utilization review: Development and maintenance of written policies and procedures for use by managed care organization and subcontractors
Each managed care organization shall: 1. Develop and maintain written policies and procedures setting forth the manner in which it conducts utilization review; and 2. Require any person with whom it subcontracts to provide utilization review to use the same policies and procedures developed pursuant to subsection 1.
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