Denial of payment for unrelated services: Requirements for notification; liability of injured employee; appeal.
1. If an insurer, organization for managed care or employer who provides accident benefits for injured employees pursuant to NRS 616C.265 denies payment for some or all of the services itemized on a statement submitted by a provider of health care on the sole basis that those services were not related to the employee’s industrial injury or occupational disease, the insurer, organization for managed care or employer shall, at the same time that it sends notification to the provider of health care of the denial, send a copy of the statement to the injured employee and notify the injured employee that it has denied payment. The notification sent to the injured employee must:
(a) State the relevant amount requested as payment in the statement, that the reason for denying payment is that the services were not related to the industrial injury or occupational disease and that, pursuant to subsection 2, the injured employee will be responsible for payment of the relevant amount if he does not, in a timely manner, appeal the denial pursuant to NRS 616C.305 and 616C.315 to 616C.385, inclusive, or appeals but is not successful.
(b) Include an explanation of the injured employee’s right to request a hearing to appeal the denial pursuant to NRS 616C.305 and 616C.315 to 616C.385, inclusive, and a suitable form for requesting a hearing to appeal the denial.
2. An injured employee who does not, in a timely manner, appeal the denial of payment for the services rendered or who appeals the denial but is not successful is responsible for payment of the relevant charges on the itemized statement.
3. To succeed on appeal, the injured employee must show that the:
(a) Services provided were related to the employee’s industrial injury or occupational disease; or
(b) Insurer, organization for managed care or employer who provides accident benefits for injured employees pursuant to NRS 616C.265 gave prior authorization for the services rendered and did not withdraw that prior authorization before the services of the provider of health care were rendered.
Last modified: February 25, 2006