NRS683A.372. Approval to conduct external reviews: Minimum qualifications; conflicts of interest.

      1.  To be approved under NRS 683A.3715 to conduct external reviews, an independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process which include, without limitation:

      (a) A quality assurance mechanism which ensures:

             (1) That an external review is conducted within the specified time frames and required notices are provided in a timely manner;

             (2) The selection of qualified and impartial clinical reviewers to conduct external reviews on behalf of the independent review organization, suitable matching of reviewers to specific cases and that the independent review organization employs or contracts with an adequate number of clinical reviewers to meet this requirement;

             (3) The confidentiality of medical and treatment records and clinical review criteria; and

             (4) That a person employed by or under contract with the independent review organization adheres to the requirements of the external review process;

      (b) A toll-free telephone service that is capable of accepting, recording or providing appropriate instruction relating to external reviews to incoming telephone callers 24 hours a day, 7 days a week; and

      (c) An agreement to maintain and provide to the Office for Consumer Health Assistance the information required pursuant to NRS 695G.303.

      2.  A clinical reviewer assigned by an independent review organization to conduct an external review must be a physician or other appropriate health care provider who must:

      (a) Be an expert in the treatment of the covered person’s medical condition that is the subject of the external review;

      (b) Be knowledgeable about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition as the covered person;

      (c) Hold a nonrestricted license in a state or territory of the United States and, if a physician, hold a current certification by a specialty board of the American Board of Medical Specialties in the area or areas appropriate to the subject of the external review; and

      (d) Have no history of disciplinary actions or sanctions, including loss of staff privileges or participation restrictions, that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body that raise a substantial question as to the clinical reviewer’s physical, mental or professional competence or moral character.

      3.  In addition to the requirements set forth in subsection 1, an independent review organization may not own or control, be a subsidiary of or in any way be owned or controlled by, or exercise control with a health benefit plan, a national, state or local trade association of health benefit plans, or a national, state or local trade association of health care providers.

      4.  In addition to the requirements set forth in subsections 1, 2 and 3, to be approved pursuant to NRS 683A.3715 to conduct an external review of a specific case, neither the independent review organization selected to conduct the external review nor a clinical reviewer assigned by the independent review organization to conduct the external review may have a material professional, familial or financial conflict of interest with any of the following:

      (a) The health carrier that is the subject of the external review;

      (b) The covered person whose treatment is the subject of the external review or the covered person’s authorized representative;

      (c) Any officer, director or management employee of the health carrier that is the subject of the external review;

      (d) The health care provider, the health care provider’s medical group or independent practice association recommending the health care service or treatment that is the subject of the external review;

      (e) The facility at which the recommended health care service or treatment would be provided; or

      (f) The developer or manufacturer of the principal drug, device, procedure or other therapy being recommended for the covered person whose treatment is the subject of the external review.

      5.  In determining whether an independent review organization or a clinical reviewer of the independent review organization has a material professional, familial or financial conflict of interest for purposes of subsection 4, the Office for Consumer Health Assistance shall take into consideration situations where the independent review organization to be assigned to conduct an external review of a specific case or a clinical reviewer to be assigned by the independent review organization to conduct an external review of a specific case may have an apparent professional, familial or financial relationship or connection with a person described in subsection 4, but that the characteristics of that relationship or connection are such that they are not a material professional, familial or financial conflict of interest that results in the disapproval of the independent review organization or the clinical reviewer from conducting the external review.

      6.  The Commissioner shall initially review and periodically review the standards of a nationally recognized private accrediting entity for accreditation of independent review organizations to determine whether the entity’s standards are equivalent to or exceed the minimum qualifications established in this section. The Commissioner may accept a review conducted by the National Association of Insurance Commissioners for the purpose of the determination under this subsection and subsection 7.

      7.  Upon request, a nationally recognized private accrediting entity shall make its current standards for the accreditation of independent review organizations available to the Commissioner or to the National Association of Insurance Commissioners in order for the Commissioner to determine if the entity’s standards are equivalent to or exceed the minimum qualifications established in this section. The Commissioner may exclude any private accrediting entity that is not reviewed by the National Association of Insurance Commissioners.

      8.  An independent review organization must be unbiased. An independent review organization shall establish and maintain written procedures to ensure that it is unbiased in addition to any other procedures required under this section.

      9.  As used in this section, the words and terms defined in NRS 695G.012 to 695G.085, inclusive, have the meanings ascribed to them in those sections.

      (Added to NRS by 2011, 3354)