Senate Bill No. 99Senator OConnell (by request)
CHAPTER……….
AN ACT relating to insurance; revising provisions governing the prompt payment by insurers of approved claims to providers of health care; revising the rate of interest applicable to the late payment of such claims; prohibiting the assessment of fees against providers of health care to be included on a list of providers of health care; establishing an administrative fine against insurers who do not substantially comply with the provisions requiring prompt payment of approved claims to providers of health care; allowing an employee who is injured or who contracts an occupational disease outside this state to receive compensation from the uninsured employers claim fund under certain circumstances; and providing other matters properly relating thereto.
THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN
SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS:
1-1 Section 1.NRS 679B.138 is hereby amended to read as follows:
1-2 679B.138 1. The commissioner shall adopt regulations which require
1-3 the use of uniform claim forms and billing codes and the ability to make
1-4 compatible electronic data transfers for all insurers and administrators
1-5 authorized to conduct business in this state relating to a health care plan or
1-6 health insurance or providing or arranging for the provision of health care
1-7 services, including, without limitation, an insurer that issues a policy of
1-8 health insurance, an insurer that issues a policy of group health insurance,
1-9 a carrier serving small employers, a fraternal benefit society, a hospital or
1-10 medical service corporation, a health maintenance organization, a plan for
1-11 dental care and a prepaid limited health service organization. The
1-12 regulations must include, without limitation, a uniform billing format to
1-13 be used for the submission of claims to such insurers and
1-14 administrators.
1-15 2. As used in this section:
1-16 (a) Administrator has the meaning ascribed to it in NRS 683A.025.
1-17 (b) Health care plan means a policy, contract, certificate or agreement
1-18 offered or issued by an insurer to provide, deliver, arrange for, pay for or
1-19 reimburse any of the costs of health care services.
1-20 Sec. 1.5. NRS 683A.0879 is hereby amended to read as follows:
1-21 683A.0879 1. Except as otherwise provided in subsection 2, an
1-22 administrator shall approve or deny a claim relating to health insurance
1-23 coverage within 30 days after the administrator receives the claim. If the
1-24 claim is approved, the administrator shall pay the claim within 30 days
1-25 after it is approved. [If] Except as otherwise provided in this section, if
1-26 the approved claim is not paid within that period, the administrator shall
1-27 pay interest on the claim at [the] a rate of interest [established pursuant to
1-28 NRS 99.040 unless a different rate of interest is established pursuant to an
1-29 express written contract between the administrator and the provider of
1-30 health care.] equal to the prime rate at the largest bank in Nevada, as
1-31 ascertained by the commissioner of financial institutions, on January 1
1-32 or July 1, as the case may be, immediately preceding the date on which
1-33 the payment was due, plus 6 percent. The interest must be calculated from
1-34 30 days after the date on which the claim is approved until the date on
1-35 which the claim is paid.
1-36 2. If the administrator requires additional information to determine
1-37 whether to approve or deny the claim, he shall notify the claimant of his
2-1 request for the additional information within 20 days after he receives the
2-2 claim. The administrator shall notify the provider of health care of all the
2-3 specific reasons for the delay in approving or denying the claim. The
2-4 administrator shall approve or deny the claim within 30 days after
2-5 receiving the additional information. If the claim is approved, the
2-6 administrator shall pay the claim within 30 days after he receives the
2-7 additional information. If the approved claim is not paid within that
2-8 period, the administrator shall pay interest on the claim in the manner
2-9 prescribed in subsection 1.
2-10 3. An administrator shall not request a claimant to resubmit
2-11 information that the claimant has already provided to the administrator,
2-12 unless the administrator provides a legitimate reason for the request and
2-13 the purpose of the request is not to delay the payment of the claim, harass
2-14 the claimant or discourage the filing of claims.
2-15 4. An administrator shall not pay only part of a claim that has been
2-16 approved and is fully payable.
2-17 5. A court shall award costs and reasonable attorneys fees to the
2-18 prevailing party in an action brought pursuant to this section.
2-19 6. The payment of interest provided for in this section for the late
2-20 payment of an approved claim may be waived only if the payment was
2-21 delayed because of an act of God or another cause beyond the control of
2-22 the administrator.
2-23 7. The commissioner may require an administrator to provide
2-24 evidence which demonstrates that the administrator has substantially
2-25 complied with the requirements set forth in this section, including,
2-26 without limitation, payment within 30 days of at least 95 percent of
2-27 approved claims or at least 90 percent of the total dollar amount for
2-28 approved claims. If the commissioner determines that an administrator
2-29 is not in substantial compliance with the requirements set forth in this
2-30 section, the commissioner may require the administrator to pay an
2-31 administrative fine in an amount to be determined by the commissioner.
2-32 Sec. 2. NRS 689A.035 is hereby amended to read as follows:
2-33 689A.035 An insurer [may] shall not charge a provider of health care
2-34 a fee to include the name of the provider on a list of providers of health
2-35 care given by the insurer to its insureds. [The amount of the fee must be
2-36 reasonable and must not exceed an amount that is directly related to the
2-37 administrative costs of the insurer to include the provider on the list.]
2-38 Sec. 3. NRS 689A.410 is hereby amended to read as follows:
2-39 689A.410 1. Except as otherwise provided in subsection 2, an insurer
2-40 shall approve or deny a claim relating to a policy of health insurance
2-41 within 30 days after the insurer receives the claim. If the claim is
2-42 approved, the insurer shall pay the claim within 30 days after it is
2-43 approved. [If] Except as otherwise provided in this section, if the
2-44 approved claim is not paid within that period, the insurer shall pay interest
2-45 on the claim at [the] a rate of interest [established pursuant to NRS 99.040
2-46 unless a different rate of interest is established pursuant to an express
2-47 written contract between the insurer and the provider of health care.] equal
2-48 to the prime rate at the largest bank in Nevada, as ascertained by the
2-49 commissioner of financial institutions, on January 1 or July 1, as the
2-50 case may be, immediately preceding the date on which the payment was
2-51 due, plus 6 percent. The
3-1 interest must be calculated from 30 days after the date on which the claim
3-2 is approved until the date on which the claim is paid.
3-3 2. If the insurer requires additional information to determine whether
3-4 to approve or deny the claim, it shall notify the claimant of its request for
3-5 the additional information within 20 days after it receives the claim. The
3-6 insurer shall notify the provider of health care of all the specific reasons
3-7 for the delay in approving or denying the claim. The insurer shall approve
3-8 or deny the claim within 30 days after receiving the additional
3-9 information. If the claim is approved, the insurer shall pay the claim
3-10 within 30 days after it receives the additional information. If the approved
3-11 claim is not paid within that period, the insurer shall pay interest on the
3-12 claim in the manner prescribed in subsection 1.
3-13 3. An insurer shall not request a claimant to resubmit information that
3-14 the claimant has already provided to the insurer, unless the insurer
3-15 provides a legitimate reason for the request and the purpose of the request
3-16 is not to delay the payment of the claim, harass the claimant or discourage
3-17 the filing of claims.
3-18 4. An insurer shall not pay only part of a claim that has been approved
3-19 and is fully payable.
3-20 5. A court shall award costs and reasonable attorneys fees to the
3-21 prevailing party in an action brought pursuant to this section.
3-22 6. The payment of interest provided for in this section for the late
3-23 payment of an approved claim may be waived only if the payment was
3-24 delayed because of an act of God or another cause beyond the control of
3-25 the insurer.
3-26 7. The commissioner may require an insurer to provide evidence
3-27 which demonstrates that the insurer has substantially complied with the
3-28 requirements set forth in this section, including, without limitation,
3-29 payment within 30 days of at least 95 percent of approved claims or at
3-30 least 90 percent of the total dollar amount for approved claims. If the
3-31 commissioner determines that an insurer is not in substantial
3-32 compliance with the requirements set forth in this section, the
3-33 commissioner may require the insurer to pay an administrative fine in
3-34 an amount to be determined by the commissioner.
3-35 Sec. 4. NRS 689B.015 is hereby amended to read as follows:
3-36 689B.015 An insurer that issues a policy of group health insurance
3-37 [may] shall not charge a provider of health care a fee to include the name
3-38 of the provider on a list of providers of health care given by the insurer to
3-39 its insureds. [The amount of the fee must be reasonable and must not
3-40 exceed an amount that is directly related to the administrative costs of the
3-41 insurer to include the provider on the list.]
3-42 Sec. 5. NRS 689B.255 is hereby amended to read as follows:
3-43 689B.255 1. Except as otherwise provided in subsection 2, an insurer
3-44 shall approve or deny a claim relating to a policy of group health insurance
3-45 or blanket insurance within 30 days after the insurer receives the claim. If
3-46 the claim is approved, the insurer shall pay the claim within 30 days after
3-47 it is approved. [If] Except as otherwise provided in this section, if the
3-48 approved claim is not paid within that period, the insurer shall pay interest
3-49 on the claim at [the] a rate of interest [established pursuant to NRS 99.040
3-50 unless a different rate of interest is established pursuant to an express
4-1 written contract between the insurer and the provider of health care.] equal
4-2 to the prime rate at the largest bank in Nevada, as ascertained by the
4-3 commissioner of financial institutions, on January 1 or July 1, as the
4-4 case may be, immediately preceding the date on which the payment was
4-5 due, plus 6 percent. The interest must be calculated from 30 days after the
4-6 date on which the claim is approved until the date on which the claim is
4-7 paid.
4-8 2. If the insurer requires additional information to determine whether
4-9 to approve or deny the claim, it shall notify the claimant of its request for
4-10 the additional information within 20 days after it receives the claim. The
4-11 insurer shall notify the provider of health care of all the specific reasons
4-12 for the delay in approving or denying the claim. The insurer shall approve
4-13 or deny the claim within 30 days after receiving the additional
4-14 information. If the claim is approved, the insurer shall pay the claim
4-15 within 30 days after it receives the additional information. If the approved
4-16 claim is not paid within that period, the insurer shall pay interest on the
4-17 claim in the manner prescribed in subsection 1.
4-18 3. An insurer shall not request a claimant to resubmit information that
4-19 the claimant has already provided to the insurer, unless the insurer
4-20 provides a legitimate reason for the request and the purpose of the request
4-21 [in] is not to delay the payment of the claim, harass the claimant or
4-22 discourage the filing of claims.
4-23 4. An insurer shall not pay only part of a claim that has been approved
4-24 and is fully payable.
4-25 5. A court shall award costs and reasonable attorneys fees to the
4-26 prevailing party in an action brought pursuant to this section.
4-27 6. The payment of interest provided for in this section for the late
4-28 payment of an approved claim may be waived only if the payment was
4-29 delayed because of an act of God or another cause beyond the control of
4-30 the insurer.
4-31 7. The commissioner may require an insurer to provide evidence
4-32 which demonstrates that the insurer has substantially complied with the
4-33 requirements set forth in this section, including, without limitation,
4-34 payment within 30 days of at least 95 percent of approved claims or at
4-35 least 90 percent of the total dollar amount for approved claims. If the
4-36 commissioner determines that an insurer is not in substantial
4-37 compliance with the requirements set forth in this section, the
4-38 commissioner may require the insurer to pay an administrative fine in
4-39 an amount to be determined by the commissioner.
4-40 Sec. 6. NRS 689C.435 is hereby amended to read as follows:
4-41 689C.435 A carrier serving small employers and a carrier that offers a
4-42 contract to a voluntary purchasing group [may] shall not charge a provider
4-43 of health care a fee to include the name of the provider on a list of
4-44 providers of health care given by the carrier to its insureds. [The amount
4-45 of the fee must be reasonable and must not exceed an amount that is
4-46 directly related to the administrative costs of the carrier to include the
4-47 provider on the list.]
4-48 Sec. 7. NRS 689C.485 is hereby amended to read as follows:
4-49 689C.485 1. Except as otherwise provided in subsection 2, a carrier
4-50 serving small employers and a carrier that offers a contract to a voluntary
5-1 purchasing group shall approve or deny a claim relating to a policy of
5-2 health insurance within 30 days after the carrier receives the claim. If the
5-3 claim is approved, the carrier shall pay the claim within 30 days after it is
5-4 approved. [If] Except as otherwise provided in this section, if the
5-5 approved claim is not paid within that period, the carrier shall pay interest
5-6 on the claim at [the] a rate of interest [established pursuant to NRS 99.040
5-7 unless a different rate of interest is established pursuant to an express
5-8 written contract between the carrier and the provider of health care.] equal
5-9 to the prime rate at the largest bank in Nevada, as ascertained by the
5-10 commissioner of financial institutions, on January 1 or July 1, as the
5-11 case may be, immediately preceding the date on which the payment was
5-12 due, plus 6 percent. The interest must be calculated from 30 days after the
5-13 date on which the claim is approved until the date on which the claim is
5-14 paid.
5-15 2. If the carrier requires additional information to determine whether to
5-16 approve or deny the claim, it shall notify the claimant of its request for the
5-17 additional information within 20 days after it receives the claim. The
5-18 carrier shall notify the provider of health care of all the specific reasons for
5-19 the delay in approving or denying the claim. The carrier shall approve or
5-20 deny the claim within 30 days after receiving the additional information. If
5-21 the claim is approved, the carrier shall pay the claim within 30 days after it
5-22 receives the additional information. If the approved claim is not paid
5-23 within that period, the carrier shall pay interest on the claim in the manner
5-24 prescribed in subsection 1.
5-25 3. A carrier shall not request a claimant to resubmit information that
5-26 the claimant has already provided to the carrier, unless the carrier provides
5-27 a legitimate reason for the request and the purpose of the request is not to
5-28 delay the payment of the claim, harass the claimant or discourage the
5-29 filing of claims.
5-30 4. A carrier shall not pay only part of a claim that has been approved
5-31 and is fully payable.
5-32 5. A court shall award costs and reasonable attorneys fees to the
5-33 prevailing party in an action brought pursuant to this section.
5-34 6. The payment of interest provided for in this section for the late
5-35 payment of an approved claim may be waived only if the payment was
5-36 delayed because of an act of God or another cause beyond the control of
5-37 the carrier.
5-38 7. The commissioner may require a carrier to provide evidence
5-39 which demonstrates that the carrier has substantially complied with the
5-40 requirements set forth in this section, including, without limitation,
5-41 payment within 30 days of at least 95 percent of approved claims or at
5-42 least 90 percent of the total dollar amount for approved claims. If the
5-43 commissioner determines that a carrier is not in substantial compliance
5-44 with the requirements set forth in this section, the commissioner may
5-45 require the carrier to pay an administrative fine in an amount to be
5-46 determined by the commissioner.
5-47 Sec. 8. NRS 695A.095 is hereby amended to read as follows:
5-48 695A.095 A society [may] shall not charge a provider of health care a
5-49 fee to include the name of the provider on a list of providers of health care
5-50 given by the society to its insureds. [The amount of the fee must be
6-1 reasonable and must not exceed an amount that is directly related to the
6-2 administrative costs of the society to include the provider on the list.]
6-3 Sec. 9. NRS 695B.035 is hereby amended to read as follows:
6-4 695B.035 A corporation subject to the provisions of this chapter [may]
6-5 shall not charge a provider of health care a fee to include the name of the
6-6 provider on a list of providers of health care given by the corporation to its
6-7 insureds. [The amount of the fee must be reasonable and must not exceed
6-8 an amount that is directly related to the administrative costs of the
6-9 corporation to include the provider on the list.]
6-10 Sec. 10. NRS 695B.2505 is hereby amended to read as follows:
6-11 695B.2505 1. Except as otherwise provided in subsection 2, a
6-12 corporation subject to the provisions of this chapter shall approve or deny
6-13 a claim relating to a contract for dental, hospital or medical services within
6-14 30 days after the corporation receives the claim. If the claim is approved,
6-15 the corporation shall pay the claim within 30 days after it is approved. [If]
6-16 Except as otherwise provided in this section, if the approved claim is not
6-17 paid within that period, the corporation shall pay interest on the claim at
6-18 [the] a rate of interest [established pursuant to NRS 99.040 unless a
6-19 different rate of interest is established pursuant to an express written
6-20 contract between the corporation and the provider of health care.] equal to
6-21 the prime rate at the largest bank in Nevada, as ascertained by the
6-22 commissioner of financial institutions, on January 1 or July 1, as the
6-23 case may be, immediately preceding the date on which the payment was
6-24 due, plus 6 percent. The interest must be calculated from 30 days after the
6-25 date on which the claim is approved until the date on which the claim is
6-26 paid.
6-27 2. If the corporation requires additional information to determine
6-28 whether to approve or deny the claim, it shall notify the claimant of its
6-29 request for the additional information within 20 days after it receives the
6-30 claim. The corporation shall notify the provider of dental, hospital or
6-31 medical services of all the specific reasons for the delay in approving or
6-32 denying the claim. The corporation shall approve or deny the claim within
6-33 30 days after receiving the additional information. If the claim is
6-34 approved, the corporation shall pay the claim within 30 days after it
6-35 receives the additional information. If the approved claim is not paid
6-36 within that period, the corporation shall pay interest on the claim in the
6-37 manner prescribed in subsection 1.
6-38 3. A corporation shall not request a claimant to resubmit information
6-39 that the claimant has already provided to the corporation, unless the
6-40 corporation provides a legitimate reason for the request and the purpose of
6-41 the request is not to delay the payment of the claim, harass the claimant or
6-42 discourage the filing of claims.
6-43 4. A corporation shall not pay only part of a claim that has been
6-44 approved and is fully payable.
6-45 5. A court shall award costs and reasonable attorneys fees to the
6-46 prevailing party in an action brought pursuant to this section.
6-47 6. The payment of interest provided for in this section for the late
6-48 payment of an approved claim may be waived only if the payment was
6-49 delayed because of an act of God or another cause beyond the control of
6-50 the corporation.
7-1 7. The commissioner may require a corporation to provide evidence
7-2 which demonstrates that the corporation has substantially complied with
7-3 the requirements set forth in this section, including, without limitation,
7-4 payment within 30 days of at least 95 percent of approved claims or at
7-5 least 90 percent of the total dollar amount for approved claims. If the
7-6 commissioner determines that a corporation is not in substantial
7-7 compliance with the requirements set forth in this section, the
7-8 commissioner may require the corporation to pay an administrative fine
7-9 in an amount to be determined by the commissioner.
7-10 Sec. 11. Chapter 695C of NRS is hereby amended by adding thereto
7-11 the provisions set forth as sections 11.3 and 11.7 of this act.
7-12 Sec. 11.3. 1. A health maintenance organization shall not:
7-13 (a) Enter into any contract or agreement, or make any other
7-14 arrangements, with a provider for the provision of health care; or
7-15 (b) Employ a provider pursuant to a contract, an agreement or any
7-16 other arrangement to provide health care,
7-17 unless the contract, agreement or other arrangement specifically
7-18 provides that the health maintenance organization and provider agree to
7-19 the schedule for the payment of claims set forth in NRS 695C.185.
7-20 2. Any contract, agreement or other arrangement between a health
7-21 maintenance organization and a provider that is entered into or renewed
7-22 on or after October 1, 2001, that does not specifically include a provision
7-23 concerning the schedule for the payment of claims as required by
7-24 subsection 1 shall be deemed to conform with the requirements of
7-25 subsection 1 by operation of law.
7-26 Sec. 11.7. Any contract or other agreement entered into or renewed
7-27 by a health maintenance organization on or after October 1, 2001:
7-28 1. To provide health care services through managed care to
7-29 recipients of Medicaid under the state plan for Medicaid; or
7-30 2. With the division of health care financing and policy of the
7-31 department of human resources to provide insurance pursuant to the
7-32 childrens health insurance program,
7-33 must require the health maintenance organization to pay interest to a
7-34 provider of health care services on a claim that is not paid within the
7-35 time provided in the contract or agreement at a rate of interest equal to
7-36 the prime rate at the largest bank in Nevada, as ascertained by the
7-37 commissioner of financial institutions, on January 1 or July 1, as the
7-38 case may be, immediately preceding the date on which the payment was
7-39 due, plus 6 percent. The interest must be calculated from 30 days after
7-40 the date on which the claim is approved until the date on which the
7-41 claim is paid.
7-42 Sec. 12. NRS 695C.050 is hereby amended to read as follows:
7-43 695C.050 1. Except as otherwise provided in this chapter or in
7-44 specific provisions of this Title, the provisions of this Title are not
7-45 applicable to any health maintenance organization granted a certificate of
7-46 authority under this chapter. This provision does not apply to an insurer
7-47 licensed and regulated pursuant to this Title except with respect to its
7-48 activities as a health maintenance organization authorized and regulated
7-49 pursuant to this chapter.
8-1 2. Solicitation of enrollees by a health maintenance organization
8-2 granted a certificate of authority, or its representatives, must not be
8-3 construed to violate any provision of law relating to solicitation or
8-4 advertising by practitioners of a healing art.
8-5 3. Any health maintenance organization authorized under this chapter
8-6 shall not be deemed to be practicing medicine and is exempt from the
8-7 provisions of chapter 630 of NRS.
8-8 4. The provisions of NRS 695C.110, 695C.170 to 695C.200, inclusive,
8-9 [and] sections 19 and 20 of [this act,] Senate Bill No. 2 of this session,
8-10 section 11.3 of this act and NRS695C.250 and 695C.265 do not apply to
8-11 a health maintenance organization that provides health care services
8-12 through managed care to recipients of Medicaid under the state plan for
8-13 Medicaid or insurance pursuant to the childrens health insurance program
8-14 pursuant to a contract with the division of health care financing and policy
8-15 of the department of human resources. This subsection does not exempt a
8-16 health maintenance organization from any provision of this chapter for
8-17 services provided pursuant to any other contract.
8-18 5. The provisions of NRS 695C.1694 and 695C.1695 apply to a health
8-19 maintenance organization that provides health care services through
8-20 managed care to recipients of Medicaid under the state plan for Medicaid.
8-21 Sec. 13. NRS 695C.055 is hereby amended to read as follows:
8-22 695C.055 1. The provisions of NRS 449.465, 679B.158, subsections
8-23 2, 4, 18, 19 and 32 of NRS 680B.010, NRS 680B.025 to 680B.060,
8-24 inclusive, [and 695G.010 to 695G.260, inclusive,] chapter 695G of NRS
8-25 and section 16 of this act, apply to a health maintenance organization.
8-26 2. For the purposes of subsection 1, unless the context requires that a
8-27 provision apply only to insurers, any reference in those sections to
8-28 insurer must be replaced by health maintenance organization.
8-29 Sec. 14. NRS 695C.125 is hereby amended to read as follows:
8-30 695C.125 A health maintenance organization [may] shall not charge a
8-31 provider of health care a fee to include the name of the provider on a list
8-32 of providers of health care given by the health maintenance organization to
8-33 its enrollees. [The amount of the fee must be reasonable and must not
8-34 exceed an amount that is directly related to the administrative costs of the
8-35 health maintenance organization to include the provider on the list.]
8-36 Sec. 15. NRS 695C.185 is hereby amended to read as follows:
8-37 695C.185 1. Except as otherwise provided in subsection 2, a health
8-38 maintenance organization shall approve or deny a claim relating to a
8-39 health care plan within 30 days after the health maintenance organization
8-40 receives the claim. If the claim is approved, the health maintenance
8-41 organization shall pay the claim within 30 days after it is approved. [If]
8-42 Except as otherwise provided in this section, if the approved claim is not
8-43 paid within that period, the health maintenance organization shall pay
8-44 interest on the claim at [the] a rate of interest [established pursuant to NRS
8-45 99.040 unless a different rate of interest is established pursuant to an
8-46 express written contract between the health maintenance organization and
8-47 the provider of health care.] equal to the prime rate at the largest bank in
8-48 Nevada, as ascertained by the commissioner of financial institutions, on
8-49 January 1 or July 1, as the case may be, immediately preceding the date
8-50 on which the payment was due, plus 6 percent. The interest must be
8-51 calculated from
9-1 30 days after the date on which the claim is approved until the date on
9-2 which the claim is paid.
9-3 2. If the health maintenance organization requires additional
9-4 information to determine whether to approve or deny the claim, it shall
9-5 notify the claimant of its request for the additional information within 20
9-6 days after it receives the claim. The health maintenance organization shall
9-7 notify the provider of health care services of all the specific reasons for the
9-8 delay in approving or denying the claim. The health maintenance
9-9 organization shall approve or deny the claim within 30 days after receiving
9-10 the additional information. If the claim is approved, the health
9-11 maintenance organization shall pay the claim within 30 days after it
9-12 receives the additional information. If the approved claim is not paid
9-13 within that period, the health maintenance organization shall pay interest
9-14 on the claim in the manner prescribed in subsection 1.
9-15 3. A health maintenance organization shall not request a claimant to
9-16 resubmit information that the claimant has already provided to the health
9-17 maintenance organization, unless the health maintenance organization
9-18 provides a legitimate reason for the request and the purpose of the request
9-19 is not to delay the payment of the claim, harass the claimant or discourage
9-20 the filing of claims.
9-21 4. A health maintenance organization shall not pay only part of a claim
9-22 that has been approved and is fully payable.
9-23 5. A court shall award costs and reasonable attorneys fees to the
9-24 prevailing party in an action brought pursuant to this section.
9-25 6. The payment of interest provided for in this section for the late
9-26 payment of an approved claim may be waived only if the payment was
9-27 delayed because of an act of God or another cause beyond the control of
9-28 the health maintenance organization.
9-29 7. The commissioner may require a health maintenance organization
9-30 to provide evidence which demonstrates that the health maintenance
9-31 organization has substantially complied with the requirements set forth
9-32 in this section, including, without limitation, payment within 30 days of
9-33 at least 95 percent of approved claims or at least 90 percent of the total
9-34 dollar amount for approved claims. If the commissioner determines that
9-35 a health maintenance organization is not in substantial compliance with
9-36 the requirements set forth in this section, the commissioner may require
9-37 the health maintenance organization to pay an administrative fine in an
9-38 amount to be determined by the commissioner.
9-39 Sec. 16. Chapter 695G of NRS is hereby amended by adding thereto a
9-40 new section to read as follows:
9-41 A managed care organization that establishes a panel of providers of
9-42 health care for the purpose of offering health care services pursuant to
9-43 chapter 689A, 689B, 689C, 695A, 695B or 695C of NRS shall not charge
9-44 a provider of health care a fee to include the name of the provider on the
9-45 panel of providers of health care.
9-46 Sec. 17. Chapter 616C of NRS is hereby amended by adding thereto
9-47 the provisions set forth as sections 18 and 19 of this act.
9-48 Sec. 18.1. Except as otherwise provided in this section, an insurer
9-49 shall approve or deny a bill for accident benefits received from a
9-50 provider of health care within 30 calendar days after the insurer receives
9-51 the bill.
10-1 If the bill for accident benefits is approved, the insurer shall pay the bill
10-2 within 30 calendar days after it is approved. Except as otherwise provided
10-3 in this section, if the approved bill for accident benefits is not paid within
10-4 that period, the insurer shall pay interest to the provider of health care at
10-5 a rate of interest equal to the prime rate at the largest bank in Nevada,
10-6 as ascertained by the commissioner of financial institutions, on January
10-7 1 or July 1, as the case may be, immediately preceding the date on which
10-8 the payment was due, plus 6 percent. The interest must be calculated
10-9 from 30 calendar days after the date on which the bill is approved until
10-10 the date on which the bill is paid.
10-11 2. If an insurer needs additional information to determine whether to
10-12 approve or deny a bill for accident benefits received from a provider of
10-13 health care, he shall notify the provider of health care of his request for
10-14 the additional information within 20 calendar days after he receives the
10-15 bill. The insurer shall notify the provider of health care of all the
10-16 specific reasons for the delay in approving or denying the bill for
10-17 accident benefits. Upon the receipt of such a request, the provider of
10-18 health care shall furnish the additional information to the insurer within
10-19 20 calendar days after receiving the request. If the provider of health
10-20 care fails to furnish the additional information within that period, the
10-21 provider of health care is not entitled to the payment of interest to which
10-22 he would otherwise be entitled for the late payment of the bill for
10-23 accident benefits. The insurer shall approve or deny the bill for accident
10-24 benefits within 20 calendar days after he receives the additional
10-25 information. If the bill for accident benefits is approved, the insurer
10-26 shall pay the bill within 20 calendar days after he receives the additional
10-27 information. Except as otherwise provided in this subsection, if the
10-28 approved bill for accident benefits is not paid within that period, the
10-29 insurer shall pay interest to the provider of health care at the rate set
10-30 forth in subsection 1. The interest must be calculated from 20 calendar
10-31 days after the date on which the insurer receives the additional
10-32 information until the date on which the bill is paid.
10-33 3. An insurer shall not request a provider of health care to resubmit
10-34 information that the provider of health care has previously provided to
10-35 the insurer, unless the insurer provides a legitimate reason for the
10-36 request and the purpose of the request is not to delay the payment of the
10-37 accident benefits, harass the provider of health care or discourage the
10-38 filing of claims.
10-39 4. An insurer shall not pay only a portion of a bill for accident
10-40 benefits that has been approved and is fully payable.
10-41 5. The administrator may require an insurer to provide evidence
10-42 which demonstrates that the insurer has substantially complied with the
10-43 requirements of this section, including, without limitation, payment
10-44 within the time required of at least 95 percent of approved accident
10-45 benefits or at least 90 percent of the total dollar amount of approved
10-46 accident benefits. If the administrator determines that an insurer is not
10-47 in substantial compliance with the requirements of this section, the
10-48 administrator may require the insurer to pay an administrative fine in
10-49 an amount to be determined by the administrator.
11-1 6. The payment of interest provided for in this section for the late
11-2 payment of an approved claim may be waived only if the payment was
11-3 delayed because of an act of God or another cause beyond the control of
11-4 the insurer.
11-5 7. Payments made by an insurer pursuant to this section are not an
11-6 admission of liability for the accident benefits or any portion of the
11-7 accident benefits.
11-8 Sec. 19.1. If an insurer, organization for managed care or
11-9 employer who provides accident benefits for injured employees pursuant
11-10 to NRS 616C.265 denies payment for some or all of the services itemized
11-11 on a statement submitted by a provider of health care on the sole basis
11-12 that those services were not related to the employees industrial injury or
11-13 occupational disease, the insurer, organization for managed care or
11-14 employer shall, at the same time that it sends notification to the provider
11-15 of health care of the denial, send a copy of the statement to the injured
11-16 employee and notify the injured employee that it has denied payment.
11-17 The notification sent to the injured employee must:
11-18 (a) State the relevant amount requested as payment in the statement,
11-19 that the reason for denying payment is that the services were not related
11-20 to the industrial injury or occupational disease and that, pursuant to
11-21 subsection 2, the injured employee will be responsible for payment of the
11-22 relevant amount if he does not, in a timely manner, appeal the denial
11-23 pursuant to NRS 616C.305 and 616C.315 to 616C.385, inclusive, or
11-24 appeals but is not successful.
11-25 (b) Include an explanation of the injured employees right to request a
11-26 hearing to appeal the denialGreen numbers along left margin indicate location on the printed bill (e.g., 5-15 indicates page 5, line 15). pursuant to NRS 616C.305 and 616C.315 to
11-27 616C.385, inclusive, and a suitable form for requesting a hearing to
11-28 appeal the denial.
11-29 2. An injured employee who does not, in a timely manner, appeal the
11-30 denial of payment for the services rendered or who appeals the denial
11-31 but is not successful is responsible for payment of the relevant charges
11-32 on the itemized statement.
11-33 3. To succeed on appeal, the injured employee must show that the:
11-34 (a) Services provided were related to the employees industrial injury
11-35 or occupational disease; or
11-36 (b) Insurer, organization for managed care or employer who provides
11-37 accident benefits for injured employees pursuant to NRS 616C.265 gave
11-38 prior authorization for the services rendered and did not withdraw that
11-39 prior authorization before the services of the provider of health care
11-40 were rendered.
11-41 Sec. 20.NRS 616C.065 is hereby amended to read as follows:
11-42 616C.065 1. [Within] Except as otherwise provided in section 18 of
11-43 this act, within 30 days after the insurer has been notified of an industrial
11-44 accident, every insurer shall:
11-45 (a) Commence payment of a claim for compensation; or
11-46 (b) Deny the claim and notify the claimant and administrator that the
11-47 claim has been denied.
11-48 Payments made by an insurer pursuant to this section are not an admission
11-49 of liability for the claim or any portion of the claim.
12-1 2. [If] Except as otherwise provided in this subsection, if an insurer
12-2 unreasonably delays or refuses to pay the claim within 30 days after the
12-3 insurer has been notified of an industrial accident, the insurer shall pay
12-4 upon order of the administrator an additional amount equal to three times
12-5 the amount specified in the order as refused or unreasonably delayed. This
12-6 payment is for the benefit of the claimant and must be paid to him with the
12-7 compensation assessed pursuant to chapters 616A to 617, inclusive, of
12-8 NRS. The provisions of this section do not apply to the payment of a bill
12-9 for accident benefits that is governed by the provisions of section 18 of
12-10 this act.
12-11 Sec. 21.NRS 616C.135 is hereby amended to read as follows:
12-12 616C.135 1. A provider of health care who accepts a patient as a
12-13 referral for the treatment of an industrial injury or an occupational disease
12-14 may not charge the patient for any treatment related to the industrial injury
12-15 or occupational disease, but must charge the insurer. The provider of
12-16 health care may charge the patient for any [other unrelated services which
12-17 are requested in writing by the patient.] services that are not related to the
12-18 employees industrial injury or occupational disease.
12-19 2. The insurer is liable for the charges for approved services related to
12-20 the industrial injury or occupational disease if the charges do not exceed:
12-21 (a) The fees established in accordance with NRS 616C.260 or the usual
12-22 fee charged by that person or institution, whichever is less; and
12-23 (b) The charges provided for by the contract between the provider of
12-24 health care and the insurer or the contract between the provider of health
12-25 care and the organization for managed care.
12-26 3. If a provider of health care, an organization for managed care, an
12-27 insurer or an employer violates the provisions of this section, the
12-28 administrator shall impose an administrative fine of not more than $250
12-29 for each violation.
12-30 Sec. 22. NRS 616C.220 is hereby amended to read as follows:
12-31 616C.220 1. The division shall designate one:
12-32 (a) Third-party administrator who has a valid certificate issued by the
12-33 commissioner pursuant to NRS 683A.085; or
12-34 (b) Insurer, other than a self-insured employer or association of self
12-35 -insured public or private employers,
12-36 to administer claims against the uninsured employers claim fund. The
12-37 designation must be made pursuant to reasonable competitive bidding
12-38 procedures established by the administrator.
12-39 2. [An] Except as otherwise provided in this subsection, an employee
12-40 may receive compensation from the uninsured employers claim fund if:
12-41 (a) He was hired in this state or he is regularly employed in this state;
12-42 (b) He suffers an accident or injury [in this state] which arises out of
12-43 and in the course of his employment [;] :
12-44 (1) In this state; or
12-45 (2) While on temporary assignment outside the state for a period of
12-46 not more than 12 months;
12-47 (c) He files a claim for compensation with the division; and
12-48 (d) He makes an irrevocable assignment to the division of a right to be
12-49 subrogated to the rights of the injured employee pursuant to
12-50 NRS 616C.215.
13-1 An employee who suffers an accident or injury while on temporary
13-2 assignment outside the state is not eligible to receive compensation from
13-3 the uninsured employers claim fund unless he has been denied
13-4 workers compensation in the state in which the accident or injury
13-5 occurred.
13-6 3. If the division receives a claim pursuant to subsection 2, the division
13-7 shall immediately notify the employer of the claim.
13-8 4. For the purposes of this section, the employer has the burden of
13-9 proving that he provided mandatory industrial insurance coverage for the
13-10 employee or that he was not required to maintain industrial insurance for
13-11 the employee.
13-12 5. Any employer who has failed to provide mandatory coverage
13-13 required by the provisions of chapters 616A to 616D, inclusive, of NRS is
13-14 liable for all payments made on his behalf, including any benefits,
13-15 administrative costs or attorneys fees paid from the uninsured employers
13-16 claim fund or incurred by the division.
13-17 6. The division:
13-18 (a) May recover from the employer the payments made by the division
13-19 that are described in subsection 5 and any accrued interest by bringing a
13-20 civil action in district court.
13-21 (b) In any civil action brought against the employer, is not required to
13-22 prove that negligent conduct by the employer was the cause of the
13-23 employees injury.
13-24 (c) May enter into a contract with any person to assist in the collection
13-25 of any liability of an uninsured employer.
13-26 (d) In lieu of a civil action, may enter into an agreement or settlement
13-27 regarding the collection of any liability of an uninsured employer.
13-28 7. The division shall:
13-29 (a) Determine whether the employer was insured within 30 days after
13-30 receiving notice of the claim from the employee.
13-31 (b) Assign the claim to the third-party administrator or insurer
13-32 designated pursuant to subsection 1 for administration and payment of
13-33 compensation.
13-34 Upon determining whether the claim is accepted or denied, the designated
13-35 third-party administrator or insurer shall notify the injured employee, the
13-36 named employer and the division of its determination.
13-37 8. Upon demonstration of the:
13-38 (a) Costs incurred by the designated third-party administrator or insurer
13-39 to administer the claim or pay compensation to the injured employee; or
13-40 (b) Amount that the designated third-party administrator or insurer will
13-41 pay for administrative expenses or compensation to the injured employee
13-42 and that such amounts are justified by the circumstances of the
13-43 claim,
13-44 the division shall authorize payment from the uninsured employers claim
13-45 fund.
13-46 9. Any party aggrieved by a determination regarding the
13-47 administration of an assigned claim or a determination made by the
13-48 division or by the designated third-party administrator or insurer regarding
13-49 any claim made pursuant to this section may appeal that determination
13-50 within 60 days after the determination is rendered to the hearings division
14-1 of the department of administration in the manner provided by NRS
14-2 616C.305 and 616C.315 to 616C.385, inclusive.
14-3 10. All insurers shall bear a proportionate amount of a claim made
14-4 pursuant to chapters 616A to 616D, inclusive, of NRS, and are entitled to
14-5 a proportionate amount of any collection made pursuant to this section as
14-6 an offset against future liabilities.
14-7 11. An uninsured employer is liable for the interest on any amount
14-8 paid on his claims from the uninsured employers claim fund. The interest
14-9 must be calculated at a rate equal to the prime rate at the largest bank in
14-10 Nevada, as ascertained by the commissioner of financial institutions, on
14-11 January 1 or July 1, as the case may be, immediately preceding the date of
14-12 the claim, plus 3 percent, compounded monthly, from the date the claim is
14-13 paid from the fund until payment is received by the division from the
14-14 employer.
14-15 12. Attorneys fees recoverable by the division pursuant to this section
14-16 must be:
14-17 (a) If a private attorney is retained by the division, paid at the usual and
14-18 customary rate for that attorney.
14-19 (b) If the attorney is an employee of the division, paid at the rate
14-20 established by regulations adopted by the division.
14-21 Any money collected must be deposited to the uninsured employers claim
14-22 fund.
14-23 13. In addition to any other liabilities provided for in this section, the
14-24 administrator may impose an administrative fine of not more than $10,000
14-25 against an employer if the employer fails to provide mandatory coverage
14-26 required by the provisions of chapters 616A to 616D, inclusive, of NRS.
14-27 Sec. 23. NRS 617.401 is hereby amended to read as follows:
14-28 617.401 1. The division shall designate one:
14-29 (a) Third-party administrator who has a valid certificate issued by the
14-30 commissioner pursuant to NRS 683A.085; or
14-31 (b) Insurer, other than a self-insured employer or association of self
14-32 -insured public or private employers,
14-33 to administer claims against the uninsured employers claim fund. The
14-34 designation must be made pursuant to reasonable competitive bidding
14-35 procedures established by the administrator.
14-36 2. [An] Except as otherwise provided in this subsection, an employee
14-37 may receive compensation from the uninsured employers claim fund if:
14-38 (a) He was hired in this state or he is regularly employed in this state;
14-39 (b) He contracts an occupational disease [as a result of work performed
14-40 in this state;] that arose out of and in the course of employment:
14-41 (1) In this state; or
14-42 (2) While on temporary assignment outside the state for a period of
14-43 not more than 12 months;
14-44 (c) He files a claim for compensation with the division; and
14-45 (d) He makes an irrevocable assignment to the division of a right to be
14-46 subrogated to the rights of the employee pursuant to NRS 616C.215.
14-47 An employee who contracts an occupational disease that arose out of and
14-48 in the course of employment while on temporary assignment outside the
14-49 state is not entitled to receive compensation from the uninsured
15-1 employers claim fund unless he has been denied workers compensation
15-2 in the state in which the disease was contracted.
15-3 3. If the division receives a claim pursuant to subsection 2, the division
15-4 shall immediately notify the employer of the claim.
15-5 4. For the purposes of this section, the employer has the burden of
15-6 proving that he provided mandatory coverage for occupational diseases for
15-7 the employee or that he was not required to maintain industrial insurance
15-8 for the employee.
15-9 5. Any employer who has failed to provide mandatory coverage
15-10 required by the provisions of this chapter is liable for all payments made
15-11 on his behalf, including, but not limited to, any benefits, administrative
15-12 costs or attorneys fees paid from the uninsured employers claim fund or
15-13 incurred by the division.
15-14 6. The division:
15-15 (a) May recover from the employer the payments made by the division
15-16 that are described in subsection 5 and any accrued interest by bringing a
15-17 civil action in district court.
15-18 (b) In any civil action brought against the employer, is not required to
15-19 prove that negligent conduct by the employer was the cause of the
15-20 occupational disease.
15-21 (c) May enter into a contract with any person to assist in the collection
15-22 of any liability of an uninsured employer.
15-23 (d) In lieu of a civil action, may enter into an agreement or settlement
15-24 regarding the collection of any liability of an uninsured employer.
15-25 7. The division shall:
15-26 (a) Determine whether the employer was insured within 30 days after
15-27 receiving the claim from the employee.
15-28 (b) Assign the claim to the third-party administrator or insurer
15-29 designated pursuant to subsection 1 for administration and payment of
15-30 compensation.
15-31 Upon determining whether the claim is accepted or denied, the designated
15-32 third-party administrator or insurer shall notify the injured employee, the
15-33 named employer and the division of its determination.
15-34 8. Upon demonstration of the:
15-35 (a) Costs incurred by the designated third-party administrator or insurer
15-36 to administer the claim or pay compensation to the injured employee; or
15-37 (b) Amount that the designated third-party administrator or insurer will
15-38 pay for administrative expenses or compensation to the injured employee
15-39 and that such amounts are justified by the circumstances of the
15-40 claim,
15-41 the division shall authorize payment from the uninsured employers claim
15-42 fund.
15-43 9. Any party aggrieved by a determination regarding the
15-44 administration of an assigned claim or a determination made by the
15-45 division or by the designated third-party administrator or insurer regarding
15-46 any claim made pursuant to this section may appeal that determination
15-47 within 60 days after the determination is rendered to the hearings division
15-48 of the department of administration in the manner provided by NRS
15-49 616C.305 and 616C.315 to 616C.385, inclusive.
16-1 10. All insurers shall bear a proportionate amount of a claim made
16-2 pursuant to this chapter, and are entitled to a proportionate amount of any
16-3 collection made pursuant to this section as an offset against future
16-4 liabilities.
16-5 11. An uninsured employer is liable for the interest on any amount
16-6 paid on his claims from the uninsured employers claim fund. The interest
16-7 must be calculated at a rate equal to the prime rate at the largest bank in
16-8 Nevada, as ascertained by the commissioner of financial institutions, on
16-9 January 1 or July 1, as the case may be, immediately preceding the date of
16-10 the claim, plus 3 percent, compounded monthly, from the date the claim is
16-11 paid from the fund until payment is received by the division from the
16-12 employer.
16-13 12. Attorneys fees recoverable by the division pursuant to this section
16-14 must be:
16-15 (a) If a private attorney is retained by the division, paid at the usual and
16-16 customary rate for that attorney.
16-17 (b) If the attorney is an employee of the division, paid at the rate
16-18 established by regulations adopted by the division.
16-19 Any money collected must be deposited to the uninsured employers claim
16-20 fund.
16-21 13. In addition to any other liabilities provided for in this section, the
16-22 administrator may impose an administrative fine of not more than $10,000
16-23 against an employer if the employer fails to provide mandatory coverage
16-24 required by the provisions of this chapter.
16-25 Sec. 23.5. Section 10 of Assembly Bill No. 338 of this session is
16-26 hereby amended to read as follows:
16-27 Sec. 10.NRS 616C.135 is hereby amended to read as follows:
16-28 616C.135 1. A provider of health care who accepts a patient as
16-29 a referral for the treatment of an industrial injury or an occupational
16-30 disease may not charge the patient for any treatment related to the
16-31 industrial injury or occupational disease, but must charge the insurer.
16-32 The provider of health care may charge the patient for any services
16-33 that are not related to the employees industrial injury or occupational
16-34 disease.
16-35 2. The insurer is liable for the charges for approved services
16-36 related to the industrial injury or occupational disease if the charges
16-37 do not exceed:
16-38 (a) The fees established in accordance with NRS 616C.260 or the
16-39 usual fee charged by that person or institution, whichever is less; and
16-40 (b) The charges provided for by the contract between the provider
16-41 of health care and the insurer or the contract between the provider of
16-42 health care and the organization for managed care.
16-43 3. A provider of health care may accept payment from an
16-44 injured employee who is paying in protest pursuant to section 5 of
16-45 this act for treatment or other services that the injured employee
16-46 alleges are related to the industrial injury or occupational disease.
16-47 4. If a provider of health care, an organization for managed care,
16-48 an insurer or an employer violates the provisions of this section, the
16-49 administrator shall impose an administrative fine of not more than
16-50 $250 for each violation.
17-1 Sec. 24. If a different rate of interest has been established pursuant to
17-2 an express written contract between an administrator, insurer, carrier,
17-3 corporation or health maintenance organization and a provider of health
17-4 care, the amendatory provisions of sections 1.5, 3, 5, 7, 10, 11.3, 15 and 18
17-5 of this act, relating to the amount of interest that accrues if an approved
17-6 claim is not timely paid, apply only to contracts between the administrator,
17-7 insurer, carrier, corporation or health maintenance organization and the
17-8 provider of health care that are entered into or renewed on or after
17-9 October 1, 2001.
17-10 Sec. 25. 1. This section, sections 1 to 11.7, inclusive, and 13 to 24,
17-11 inclusive, of this act become effective on October 1, 2001.
17-12 2. Section 12 of this act becomes effective at 12:01 a.m. on October 1,
17-13 2001.
17-14 20~~~~~01