Written notice to insured explaining rights of insureds regarding decision to deny coverage; notice to insured when organization denies coverage of health care service.
1. After approval by the Commissioner, each managed care organization shall provide a written notice to an insured, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the insured to file a written complaint and to obtain an expedited review pursuant to NRS 695G.210. Such a notice must be provided to an insured:
(a) At the time he receives his certificate of coverage or evidence of coverage;
(b) Any time that the managed care organization denies coverage of a health care service or limits coverage of a health care service to an insured; and
(c) Any other time deemed necessary by the Commissioner.
2. If a managed care organization denies coverage of a health care service to an insured, including, without limitation, a health maintenance organization that denies a claim related to a health care plan pursuant to NRS 695C.185, it shall notify the insured in writing within 10 working days after it denies coverage of the health care service of:
(a) The reason for denying coverage of the service;
(b) The criteria by which the managed care organization or insurer determines whether to authorize or deny coverage of the health care service;
(c) His right to:
(1) File a written complaint and the procedure for filing such a complaint;
(2) Appeal a final adverse determination pursuant to NRS 695G.241 to 695G.310, inclusive;
(3) Receive an expedited external review of a final adverse determination if the managed care organization 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, including notification of the procedure for requesting the expedited external review; and
(4) Receive assistance from any person, including an attorney, for an external review of a final adverse determination; and
(d) The telephone number of the Office for Consumer Health Assistance.
3. A written notice which is approved by the Commissioner shall be deemed to be in clear and comprehensible language that is understandable to an ordinary layperson.
Last modified: February 27, 2006