Certification; conflicts of interest; annual list.
1. An external review organization shall not conduct an external review of a final adverse determination pursuant to NRS 695G.241 to 695G.310, inclusive, unless the external review organization is certified in accordance with regulations adopted by the Commissioner. The regulations must include, without limitation, provisions setting forth:
(a) The manner in which an external review organization may apply for a certificate and the requirements for the issuance and renewal of the certificate pursuant to this section;
(b) The grounds for which the Commissioner may refuse to issue, suspend, revoke or refuse to renew a certificate issued pursuant to this section; and
(c) The manner and circumstances under which an external review organization is required to conduct its business.
2. A certificate issued pursuant to this section expires 1 year after it is issued and may be renewed in accordance with regulations adopted by the Commissioner.
3. Except as otherwise provided in subsection 6, before the Commissioner may certify an external review organization, the external review organization must:
(a) Demonstrate to the satisfaction of the Commissioner that it is able to carry out, in a timely manner, the duties of an external review organization set forth in this section and NRS 695G.241 to 695G.310, inclusive. The demonstration must include, without limitation, proof that the external review organization employs, contracts with or otherwise retains only persons who are qualified because of their education, training, professional licensing and experience to perform the duties assigned to those persons; and
(b) Provide assurances satisfactory to the Commissioner that the external review organization will:
(1) Conduct its external review activities in accordance with the provisions of this section and NRS 695G.241 to 695G.310, inclusive;
(2) Provide its determinations in a clear, consistent, thorough and timely manner; and
(3) Avoid conflicts of interest.
4. For the purposes of this section, an external review organization has a conflict of interest if the external review organization or any employee, agent or contractor of the external review organization who conducts an external review has a material professional, familial or financial interest in any person who has a substantial interest in the outcome of the external review, including, without limitation:
(a) The insured;
(b) The insurer or any officer, director or management employee of the insurer;
(c) The provider of health care services that are provided or proposed to be provided, his partner or any other member of his medical group or practice;
(d) The hospital or other licensed health care facility where the health care service or treatment that is subject to external review has been or will be provided; or
(e) A developer, manufacturer or other person who has a substantial interest in the principal procedure, equipment, drug, device or other instrumentality that is the subject of the external review.
5. The Commissioner shall not certify an external review organization that is affiliated with:
(a) A health care plan; or
(b) A national, state or local trade association.
6. An external review organization that is certified or accredited by an accrediting body that is nationally recognized shall be deemed to have satisfied all the conditions and qualifications required for certification pursuant to this section.
7. The Commissioner may charge and collect a fee for issuing or renewing a certificate of an external review organization pursuant to this section. The fee must not exceed the cost of issuing or renewing the certificate.
8. The Commissioner shall annually prepare and make available to the general public a list that includes the name of each external review organization which is issued a certificate or whose certificate is renewed pursuant to this section during the year immediately preceding the year in which the Commissioner prepares the list.
9. As used in this section:
(a) “Adverse determination” has the meaning ascribed to it in NRS 695G.012.
(b) “External review organization” has the meaning ascribed to it in NRS 695G.018.
(c) “Provider of health care” means any physician or other person who is licensed in this State or is licensed, certified or otherwise authorized by any other state to provide any health care service.
Last modified: February 27, 2006