NRS695G.251. Request for review; assignment of independent review organization; provision of documents relating to adverse determination to independent review organization.

      1.  If a covered person or a physician of a covered person receives notice of an adverse determination from a health carrier concerning the covered person, the covered person, the physician of the covered person or an authorized representative may, within 4 months after receiving notice of the adverse determination, submit a request to the Office for Consumer Health Assistance for an external review of the adverse determination.

      2.  Within 5 days after receiving a request pursuant to subsection 1, the Office for Consumer Health Assistance shall notify the covered person, the authorized representative or physician of the covered person, the agent who performed utilization review for the health carrier, if any, and the health carrier that the request has been filed with the Office for Consumer Health Assistance.

      3.  As soon as practicable after receiving a request pursuant to subsection 1, the Office for Consumer Health Assistance shall assign an independent review organization from the list maintained pursuant to NRS 683A.3715. Each assignment made pursuant to this subsection must be completed on a rotating basis.

      4.  Within 5 days after receiving notification from the Office for Consumer Health Assistance specifying the independent review organization assigned pursuant to subsection 3, the health carrier shall provide to the independent review organization all documents and materials relating to the adverse determination, including, without limitation:

      (a) Any medical records of the insured relating to the external review;

      (b) A copy of the provisions of the health benefit plan upon which the adverse determination was based;

      (c) Any documents used by the health carrier to make the adverse determination;

      (d) The reasons for the adverse determination; and

      (e) Insofar as practicable, a list that specifies each provider of health care who has provided health care to the covered person and the medical records of the provider of health care relating to the external review.

      (Added to NRS by 2003, 780; A 2011, 3412)