Authorization of recommended and covered health care services required. Each managed care organization shall authorize coverage of a health care service that has been recommended for the insured by a provider of health care acting within the scope of his practice if that service is covered by the health care plan of the insured, unless:
1. The decision not to authorize coverage is made by a physician who:
(a) Is licensed to practice medicine in the State of Nevada pursuant to chapter 630 or 633 of NRS;
(b) Possesses the education, training and expertise to evaluate the medical condition of the insured; and
(c) Has reviewed the available medical documentation, notes of the attending physician, test results and other relevant medical records of the insured.
Ê The physician may consult with other providers of health care in determining whether to authorize coverage.
2. The decision not to authorize coverage and the reason for the decision have been transmitted in writing in a timely manner to the insured, the provider of health care who recommended the service and the primary care physician of the insured, if any.
Last modified: February 27, 2006