In most cases, existing law requires the administrators of health insurance plans and certain health insurers, including the Public Employees' Benefits Program, to approve or deny a claim within 30 days after the insurer receives the claim. If the administrator or insurer approves the claim, existing law requires the administrator or insurer to pay the claim within 30 days after the claim is approved. If the administrator or insurer requires additional information to determine whether to approve or deny the claim, existing law requires the administrator or insurer to notify the claimant of its request for additional information within 20 days after the administrator or insurer receives the claim. If the administrator or insurer approves the claim after receiving such additional information from the claimant, existing law requires the administrator or insurer to pay the claim within 30 days after receiving such information. Existing law requires an administrator or insurer that fails to pay a claim within the required time period to pay interest on the claim at a prescribed rate. (NRS 287.04335, 683A.0879, 689A.410, 689B.255, 689C.335, 695A.188, 695B.2505, 695C.185, 695D.215, 695F.090) Sections 2, 5, 8-11, 14, 16, 20 and 22 of this bill replace those requirements with uniform requirements governing the time periods for the payment of health insurance claims that apply to administrators of health insurance plans and all public and private health insurers in this State, including Medicaid, insurance for employees of local governments and the Public Employees' Benefits Program. Specifically, sections 2, 5, 8-11, 14, 16, 20 and 22 require each such administrator or insurer to approve or deny a claim and, if the claim is approved, pay the claim within: (1) fifteen working days after receiving the claim, if the claim is submitted electronically; or (2) thirty working days after receiving the claim, if the claim is not submitted electronically. Sections 2, 5, 8-11, 14, 16, 20 and 22 require an administrator or insurer that needs additional information to determine whether to approve or deny a claim to request such information within 20 working days after receiving the claim. If, after receiving such additional information, the administrator or insurer approves the claim, sections 2, 5, 8-11, 14, 16, 20 and 22 require the administrator or insurer, as applicable, to pay the claim within: (1) fifteen working days after receiving the additional information, if the additional information is submitted electronically; or (2) thirty working days after receiving the additional information, if the additional information is not submitted electronically. Sections 2, 5, 8-11, 14, 16, 20 and 22 require an administrator or health insurer to annually report to the Commissioner of Insurance certain information relating to compliance with those requirements. Section 25 of this bill repeals certain provisions applicable to health maintenance organizations that are no longer necessary because existing law makes the provisions of section 16 applicable to all managed care organizations, including health maintenance organizations. (NRS 695C.055) Sections 13 and 18 of this bill update references to a section repealed by section 25 with a reference to section 16. Existing law authorizes the Commissioner to: (1) impose an administrative penalty upon determining that the administrator of a health insurance plan or certain health insurers are not in substantial compliance with the provisions of existing law governing the schedule for paying claims; and (2) suspend or revoke the certificate of registration or authority of such an administrator or insurer upon a second or subsequent determination that such an administrator or insurer is not in substantial compliance with those provisions. (NRS 287.04335, 683A.0879, 689A.410, 689B.255, 689C.335, 695B.2505, 695C.185, 695F.090) Sections 10, 14 and 16 of this bill extend those penalties to apply to fraternal benefit societies, issuers of plans for dental care and managed care organizations. Sections 2, 5, 8-11, 14 and 16 additionally authorize the Commissioner to: (1) impose an administrative penalty upon determining that the administrator of a health insurance plan or a health insurer has failed to approve or deny a claim or pay an approved claim within 60 working days after receiving the claim; and (2) suspend or revoke the certificate of registration or authority of an administrator or insurer upon a second or subsequent such determination. Section 19 of this bill makes a conforming change to require the Director of the Department of Health and Human Services to administer the provisions of section 22 in the same manner as other provisions governing Medicaid. Existing law requires certain health insurers to provide certain notice to an insured within 10 days after denying coverage. (NRS 689A.755, 689B.0295, 695B.400, 695G.230) Sections 2, 6, 7, 9, 10, 12, 14, 15, 17, 18, 20 and 22 of this bill require all public and private health insurers and administrators of health insurance plans to provide notice of the denial of a claim within 30 working days after receiving all information necessary to make a determination concerning the claim. Sections 2, 6, 7, 9, 10, 12, 14, 15, 17, 18, 20 and 22 of this bill also require the inclusion of certain additional information in such a notice. Sections 10, 14 and 16 make certain other provisions relating to the payment of claims that currently apply to most health insurers also apply to fraternal benefit societies, organizations for dental care and managed care organizations so that the requirements governing the payment of claims are uniform for all health insurers. Existing law requires a health carrier which offers or issues a network plan to notify each participating provider of health care in the network of the responsibilities of the provider of health care with respect to any applicable administrative policies and programs of the health carrier. (NRS 687B.730) Sections 3 and 22 of this bill additionally require such a health carrier or the Medicaid Program to provide to each participating provider of health care and each covered person at least annually an explanation of the process by which the health carrier or Medicaid, as applicable, will provide remittances to or pay claims submitted by participating providers of health care. Existing law requires a health carrier which offers or issues a network plan to establish procedures for the resolution of disputes between the health carrier and a participating provider of health care. (NRS 687B.820) Section 4 of this bill requires those procedures to include an efficient process by which a participating provider of health care may challenge the denial by a health carrier of a claim. Section 22 imposes a similar requirement on the Medicaid program. Sections 20 and 21 of this bill make the provisions of sections 3 and 4 applicable to local governments that provide health insurance for their employees and the Public Employees' Benefits Program, respectively. Section 1 of this bill requires the Division of Insurance of the Department of Business and Industry to establish and carry out certain programs to facilitate public knowledge and use of the provisions of this bill.

Statutes affected:
As Introduced: 679B.550, 683A.0879, 687B.730, 687B.820, 689A.410, 689A.755, 689B.0295, 689B.255, 689C.335, 695A.188, 695B.2505, 695B.400, 695C.187, 695D.215, 695G.090, 695G.230, 232.320, 287.010, 287.04335
BDR: 679B.550, 683A.0879, 687B.730, 687B.820, 689A.410, 689A.755, 689B.0295, 689B.255, 689C.335, 695A.188, 695B.2505, 695B.400, 695C.187, 695D.215, 695G.090, 695G.230, 232.320, 287.010, 287.04335