Expedited approval or denial of request.
1. A managed care organization shall approve or deny a request for an external review of a final adverse determination in an expedited manner not later than 72 hours after it receives proof from the insured’s provider of health care that failure to proceed in an expedited manner may jeopardize the life or health of the insured.
2. If a managed care organization approves a request for an external review pursuant to subsection 1, the managed care organization shall:
(a) In accordance with subsections 4 and 5, assign the request to an external review organization not later than 1 working day after approving the request; and
(b) At the time of assigning the request, provide to the external review organization all documents and materials specified in subsection 4 of NRS 695G.251.
3. An external review organization that is assigned to conduct an external review pursuant to subsection 2 shall, if it accepts the assignment:
(a) Complete its external review not later than 2 working days after receiving the assignment, unless the insured and the managed care organization agree to a longer period;
(b) Not later than 1 working day after completing its external review, notify the insured, the physician of the insured, the authorized representative of the insured, if any, and the managed care organization by telephone of its determination; and
(c) Not later than 5 working days after completing its external review, submit a written decision of its external review to the insured, the physician of the insured, the authorized representative of the insured, if any, and the managed care organization.
4. At least once each month, the Office for Consumer Health Assistance shall designate at least 2 external review organizations to conduct external reviews in an expedited manner pursuant to this section. As soon as practicable after designating an external review organization pursuant to this section, the Office for Consumer Health Assistance shall notify each managed care organization of the designation.
5. As soon as practicable after assigning an external review organization to conduct an external review pursuant to this section, the managed care organization shall notify the Office for Consumer Health Assistance of the assignment. Each assignment made by a managed care organization pursuant to this section must be completed on a rotating basis.
Last modified: February 27, 2006