NRS695G.245. Written notice of right to request external review; form; contents.

      1.  A health carrier shall notify the covered person in writing of the covered person’s right to request an external review to be conducted pursuant to NRS 695G.241 to 695G.310, inclusive, and include the appropriate statements and information set forth in subsection 2 at the same time the health carrier sends written notice of an adverse determination upon completion of the health carrier’s utilization review process set forth in NRS 683A.375 to 683A.379, inclusive, and the regulations adopted pursuant thereto.

      2.  As part of the written notice required pursuant to subsection 1, a health carrier shall include the following, or substantially equivalent, language:

 

We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested by submitting a request for external review to the Office for Consumer Health Assistance.

 

      3.  The Commissioner may prescribe by regulation the form and content of the notice required pursuant to this section.

      4.  The health carrier shall include in the notice required pursuant to subsection 1 a statement informing the covered person that:

      (a) If the covered person has a medical condition where the timeframe for completion of an expedited review of a grievance involving an adverse determination set forth in NRS 695G.200 to 695G.230, inclusive, would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, the covered person or the covered person’s authorized representative may, at the same time the covered person or the covered person’s authorized representative files a request for an expedited review of a grievance involving an adverse determination as set forth in NRS 695G.210, file a request for an expedited external review to be conducted pursuant to NRS 695G.271 and 695G.275 if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person’s treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated, and the independent review organization assigned to conduct the expedited external review will determine whether the covered person will be required to complete the expedited review of the grievance before conducting the expedited external review; and

      (b) The covered person or the covered person’s authorized representative may file a grievance under the health carrier’s internal grievance process as set forth in NRS 695G.200 to 695G.230, inclusive, but if the health carrier has not issued a written decision to the covered person or the covered person’s authorized representative within 30 days after the date on which the covered person or the covered person’s authorized representative filed the grievance with the health carrier and the covered person or the covered person’s authorized representative has not requested or agreed to a delay, the covered person or the covered person’s authorized representative may file a request for external review pursuant to NRS 695G.251 and shall be considered to have exhausted the health carrier’s internal grievance process.

      5.  In addition to the information required to be provided pursuant to subsection 1, the health carrier shall include a copy of the description of both the standard and expedited external review procedures the health carrier is required to provide pursuant to NRS 695G.307, highlighting the provisions in the external review procedures that give the covered person or the covered person’s authorized representative the opportunity to submit additional information and including any forms used to process an external review.

      6.  As part of any forms provided pursuant to subsection 3, the health carrier shall include an authorization form, or other document approved by the Commissioner that complies with the requirements of 45 C.F.R. § 164.508, by which the covered person, for purposes of conducting an external review, authorizes the health carrier and the covered person’s treating health care provider to disclose protected health information, including medical records, concerning the covered person that are pertinent to the external review.

      7.  As used in this section, “protected health information” has the meaning ascribed to it in 45 C.F.R. § 160.103.

      (Added to NRS by 2011, 3400)