o such guidelines; and (c) Provide staff to assist the committee. 3. The committee shall: (a) Select and review appropriate medical records of insureds and other data related to the quality of health care provided to insureds by providers of health care; (b) Review the clinical processes used by providers of health care in providing services; (c) Identify any problems related to the quality of health care provided to insureds; and (d) Advise providers of health care regarding issues related to quality of care. (Added to NRS by 1997, 303; A 2003, 1182) SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS NRS 695G.200 Approval; requirements; assistance for persons filing complaints; examination. 1. Each managed care organization shall establish a system for resolving complaints of an insured concerning: (a) Payment or reimbursement for covered health care services; (b) Availability, delivery or quality of covered health care services, including, without limitation, an adverse determination made pursuant to utilization review; or (c) The terms and conditions of a health care plan. The system must be approved by the Commissioner in consultation with the State Board of Health. 2. If an insured makes an oral complaint, a managed care organization shall inform the insured that if he is not satisfied with the resolution of the complaint, he must file the complaint in writing to receive further review of the complaint. 3. Each managed care organization shall: (a) Upon request, assign an employee of the managed care organization to assist an insured or other person in filing a complaint or appealing a decision of the review board; (b) Authorize an insured who appeals a decision of the review board to appear before the review board to present testimony at a hearing concerning the appeal; and (c) Authorize an insured to introduce any documentation into evidence at a hearing of a review board and require an insured to provide the documentation required by his health care plan to the review board not later than 5 business days before a hearing of the review board. 4. The Commissioner or the State Board of Health may examine the system for resolving complaints established pursuant to this section at such times as either deems necessary or appropriate. (Added to NRS by 1997, 305) NRS 695G.210 Review board; appeal; right to expedited review of complaint; notice to insured. 1. Except as otherwise provided in NRS 695G.300, a system for resolving complaints created pursuant to NRS 695G.200 must include, without limitation, an initial investigation, a review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members of the review board must be insureds who receive health care services from the managed care organization. 2. Except as otherwise provided in subsection 3, a review board shall complete its review regarding a complaint or appeal and notify the insured of its determination not later than 30 days after the complaint or appeal is filed, unless the insured and the review board have agreed to a longer period. 3. If a complaint involves an imminent and serious threat to the health of the insured, the managed care organization shall inform the insured immediately of his right to an expedited review of his complaint. If an expedited review is required, the review board shall notify the insured in writing of its determination within 72 hours after the complaint is filed. 4. Notice provided to an insured by a review board regarding a complaint must include, without limitation, an explanation of any further rights of the insured regarding the complaint that are available under his health care plan. (Added to NRS by 1997, 306; A 2003, 783) NRS 695G.220 Annual report; managed care organization to maintain records of complaints concerning something other than health care services. 1. Each managed care organization shall submit to the Commissioner and the State Board of Health an annual report regarding its system for resolving complaints established pursuant to NRS 695G.200 on a form prescribed by the Commissioner in consultation with the State Board of Health which includes, without limitation: (a) A description of the procedures used for resolving complaints of an insured; (b) The total number of complaints and appeals handled through the system for resolving complaints since the last report and a compilation of the causes underlying the complaints filed; (c) The current status of each complaint and appeal filed; and (d) The average amount of time that was needed to resolve a complaint and an appeal, if any. 2. Each managed care organization shall maintain records of complaints filed with it which concern something other than health care services and shall submit to the Commissioner a report summarizing such complaints at such times and in such format as the Commissioner may require. (Added to NRS by 1997, 306) NRS 695G.230 Written notice to insured explaining rights of insureds regarding decision to deny coverage; notice to insured when organization denies coverage of health care service. 1. After approval by the Commissioner, each managed care organization shall provide a written notice to an insured, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the insured to file a written complaint and to obtain an expedited review pursuant to NRS 695G.210. Such a notice must be provided to an insured: (a) At the time he receives his certificate of coverage or evidence of coverage; (b) Any time that the managed care organization denies coverage of a health care service or limits coverage of a health care service to an insured; and (c) Any other time deemed necessary by the Commissioner. 2. If a managed care organization denies coverage of a health care service to an insured, including, without limitation, a health maintenance organization that denies a claim related to a health care plan pursuant to NRS 695C.185, it shall notify the insured in writing within 10 working days after it denies coverage of the health care service of: (a) The reason for denying coverage of the service; (b) The criteria by which the managed care organization or insurer determines whether to authorize or deny coverage of the health care service; (c) His right to: (1) File a written complaint and the procedure for filing such a complaint; (2) Appeal a final adverse determination pursuant to NRS 695G.241 to 695G.310, inclusive; (3) Receive an expedited external review of a final adverse determination if the managed care organization receives proof from the insured’s provider of health care that failure to proceed in an expedited manner may jeopardize the life or health of the insured, including notification of the procedure for requesting the expedited external review; and (4) Receive assistance from any person, including an attorney, for an external review of a final adverse determination; and (d) The telephone number of the Office for Consumer Health Assistance. 3. A written notice which is approved by the Commissioner shall be deemed to be in clear and comprehensible language that is understandable to an ordinary layperson. (Added to NRS by 1997, 307; A 1999, 3097; 2003, 784) EXTERNAL REVIEW OF ADVERSE DETERMINATION NRS 695G.241 Adverse determination deemed final for purpose of submitting to external review organization. 1. For the purposes of NRS 695G.200 to 695G.310, inclusive, an adverse determination is final if the insured has exhausted all procedures set forth in the health care plan for reviewing the adverse determination within the managed care organ

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