Existing law requires each managed care organization to authorize coverage of a health care service that has been recommended for an insured by a provider of health care acting within the scope of his or her practice if that service is covered by the health care plan of the insured unless the decision not to authorize coverage is made by a physician who satisfies certain conditions. (NRS 695G.150) Section 2 of this bill provides that a managed care organization is also not required to authorize coverage if the decision not to authorize coverage is made by a dentist who satisfies certain conditions. Existing law: (1) requires a managed care organization to establish a system of procedures for resolving complaints of a person who is insured by a managed care organization; and (2) provides for the external review of an adverse determination by a managed care organization. (NRS 695G.200-695G.310) The requirement for the establishment of a system of procedures for resolving complaints and the provisions setting forth procedures for the external review of an adverse determination also apply to insurers that issue certain policies, plans, contracts and coverage for health insurance in this State that provide, deliver, arrange for, pay for or reimburse costs of health care through managed care, including: (1) certain health insurance provided through a plan of self-insurance for officers and employees of this State; (2) individual health insurance; (3) group health insurance; (4) health benefit plans of small employers; (5) contracts for hospital or medical services; (6) health care plans issued by health maintenance organizations; and (7) evidence of coverage issued by prepaid limited health service organizations. (NRS 287.04335, 689A.745, 689B.0285, 689C.156, 695B.380, 695C.260, 695F.230) Existing law exempts a policy or certificate that provides only dental coverage from these provisions. (NRS 695G.243) Section 3 of this bill provides that the requirement for the establishment of a system of procedures for resolving complaints and the provisions setting forth procedures for the external review of an adverse determination apply to a policy or certificate that provides only dental coverage. Existing law requires a health carrier to notify certain persons, including a covered person and his or her treating physician, of: (1) an adverse determination relating to a request for the provision of or payment for a health care service or course of treatment; and (2) certain information which must be included in such a notice, including the ability to file a request for an expedited external review if, among other conditions, the insured's treating physician makes certain written certifications relating to the recommended or requested health care service or treatment. (NRS 695G.245) Section 4 of this bill provides that a dentist may make the required written certifications. Existing law authorizes a covered person, a physician of a covered person or an authorized representative to submit a request to the Office for Consumer Health Assistance in the Department of Health and Human Services for an external review of an adverse determination. (NRS 695G.251) Section 5 of this bill authorizes a dentist of a covered person to submit such a request. Existing law requires an independent review organization that receives a request for an external review to: (1) notify the covered person, the physician of the covered person and the health carrier if any additional information is required to conduct the review; (2) forward to the health carrier any information received from a covered person or the physician of a covered person; and (3) notify the covered person, the physician of the covered person, the authorized representative of the covered person and the health carrier of its determination and reasons therefor. (NRS 695G.261) Section 6 of this bill requires the independent review organization to also: (1) notify the dentist of the covered person if any additional information is required to conduct the review; (2) forward to the health carrier any information received from the dentist of a covered person; and (3) notify the dentist of the covered person of its determination and reasons therefor. Existing law requires an independent review organization to notify a covered person, the physician of the covered person, the authorized representative, if any, and the health carrier by telephone and in writing after completing its external review. (NRS 695G.271) Section 7 of this bill requires an independent review organization to notify the dentist of a covered person, if applicable. Existing law sets forth the process by which an external review of an adverse determination must be conducted. (NRS 695G.275) Section 8 of this bill revises provisions setting forth that process to provide a covered person's treating dentist with the same powers and duties with respect to that process as a covered person's treating physician. Existing law requires the decision of an independent review organization concerning a request for an external review to be based, in part, on documentary evidence, including any recommendation of the physician of the insured. (NRS 695G.280) Section 9 of this bill requires that documentary evidence to include any recommendation of the dentist of the insured. Existing law provides a clinical peer who conducts or participates in an external review of an adverse determination immunity from liability for certain damages relating to the external review under certain circumstances. (NRS 695G.290) Section 1 of this bill revises the definition of “clinical peer” to include certain dentists.

Statutes affected:
As Introduced: 695G.016, 695G.150, 695G.243, 695G.245, 695G.251, 695G.261, 695G.271, 695G.275, 695G.280
BDR: 695G.016, 695G.150, 695G.243, 695G.245, 695G.251, 695G.261, 695G.271, 695G.275, 695G.280