ization; provision of documents relating to adverse determination to external review organization. NRS 695G.261 Review of documents by external review organization; decision of external review organization. NRS 695G.271 Expedited approval or denial of request. NRS 695G.280 Basis for decision of external review organization. NRS 695G.290 Decision in favor of insured binding on managed care organization; limitation of liability; cost for external review organization. NRS 695G.300 Submission of complaint of insured to external review organization. NRS 695G.310 Annual report; requirements. PROHIBITED ACTS NRS 695G.400 Managed care organization prohibited from interfering in or restricting certain communications. NRS 695G.405 Managed care organization prohibited from denying coverage solely because insured was intoxicated or under the influence of controlled substance; exceptions. [Effective July 1, 2006.] NRS 695G.410 Certain actions taken against provider solely because provider advocates on behalf of patient, assists patient or reports violation of law prohibited. NRS 695G.420 Offering or paying financial incentive to provider to deny, reduce, withhold, limit or delay medically necessary services prohibited. NRS 695G.430 Contracts between managed care organization and provider of health care: Form for obtaining information on provider of health care; modification; schedule of fees. _________ GENERAL PROVISIONS NRS 695G.010 Definitions. As used in this chapter, unless the context otherwise requires, the words and terms defined in NRS 695G.020 to 695G.080, inclusive, have the meanings ascribed to them in those sections. (Added to NRS by 1997, 301; A 2003, 783) NRS 695G.012 “Adverse determination” defined. “Adverse determination” means a determination of a managed care organization to deny all or part of a service or procedure that is proposed or being provided to an insured on the basis that it is not medically necessary or appropriate or is experimental or investigational. The term does not include a determination of a managed care organization that such an allocation is not a covered benefit. (Added to NRS by 2003, 779) NRS 695G.014 “Authorized representative” defined. “Authorized representative” means a person who has obtained the consent of an insured to represent him in an external review of a final adverse determination conducted pursuant to NRS 695G.241 to 695G.310, inclusive. (Added to NRS by 2003, 779) NRS 695G.016 “Clinical peer” defined. “Clinical peer” means a physician who is: 1. Engaged in the practice of medicine; and 2. Certified or is eligible for certification by a member board of the American Board of Medical Specialties in the same or similar area of practice as is the health care service that is the subject of a final adverse determination. (Added to NRS by 2003, 779) NRS 695G.018 “External review organization” defined. “External review organization” means an organization that: 1. Conducts an external review of a final adverse determination; and 2. Is certified by the Commissioner in accordance with NRS 683A.371. (Added to NRS by 2003, 779) NRS 695G.020 “Health care plan” defined. “Health care plan” means a policy, contract, certificate or agreement offered or issued by a managed care organization to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services. (Added to NRS by 1997, 301) NRS 695G.030 “Insured” defined. “Insured” means a person who receives benefits under a health care plan. (Added to NRS by 1997, 301) NRS 695G.040 “Managed care” defined. “Managed care” means a system for delivering health care services that encourages the efficient use of health care services by using employed or independently contracted providers of health care and by using various techniques which may include, without limitation: 1. Managing the health care services of an insured who has a serious, complicated, protracted or other health-related condition that requires the use of numerous providers of health care or other costly services; 2. Providing utilization review; 3. Offering financial incentives for the effective use of health care services; or 4. Any combination of those techniques. (Added to NRS by 1997, 301) NRS 695G.050 “Managed care organization” defined. “Managed care organization” means any insurer or organization authorized pursuant to this title to conduct business in this State that provides or arranges for the provision of health care services through managed care. (Added to NRS by 1997, 302) NRS 695G.055 “Medically necessary” defined. “Medically necessary” means health care services or products that a prudent physician would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and: 1. Provided in accordance with generally accepted standards of medical practice; 2. Clinically appropriate with regard to type, frequency, extent, location and duration; 3. Not primarily provided for the convenience of the patient, physician or other provider of health care; 4. Required to improve a specific health condition of an insured or to preserve his existing state of health; and 5. The most clinically appropriate level of health care that may be safely provided to the insured. (Added to NRS by 2003, 779) NRS 695G.060 “Primary care physician” defined. “Primary care physician” means a physician or group of physicians who: 1. Provides initial and primary health care services to an insured; 2. Maintains the continuity of care for the insured; and 3. May refer the insured to a specialized provider of health care. (Added to NRS by 1997, 302) NRS 695G.070 “Provider of health care” defined. “Provider of health care” means any physician, hospital or other person who is licensed or otherwise authorized in this State to furnish any health care service. (Added to NRS by 1997, 302) NRS 695G.080 “Utilization review” defined. 1. “Utilization review” means the various methods that may be used by a managed care organization to review the amount and appropriateness of the provision of a specific health care service to an insured. 2. The term does not include an external review of a final adverse determination conducted pursuant to NRS 695G.241 to 695G.310, inclusive. (Added to NRS by 1997, 302; A 2003, 783) NRS 695G.090 Applicability. 1. Except as otherwise provided in subsection 3, the provisions of this chapter apply to each organization and insurer that operates as a managed care organization and may include, without limitation, an insurer that issues a policy of health insurance, an insurer that issues a policy of individual or group health insurance, a carrier serving small employers, a fraternal benefit society, a hospital or medical service corporation and a health maintenance organization. 2. In addition to the provisions of this chapter, each managed care organization shall comply with: (a) The provisions of chapter 686A of NRS, including all obligations and remedies set forth therein; and (b) Any other applicable provision of this title. 3. The provisions of NRS 695G.164, 695G.200 to 695G.230, inclusive, and 695G.430 do not apply to a managed care organization that provides health care services to recipients of Medicaid under the State Plan for Medicaid or insurance pursuant to the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Health and Human Services. This subsection does not exempt a managed care organization from any provision o

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