ization. 2. An adverse determination shall be deemed final for the purpose of submitting the adverse determination to an external review organization for an external review: (a) If an insured exhausts all procedures set forth in the health care plan for reviewing the adverse determination within the managed care organization and the managed care organization fails to render a decision within the period required to render that decision set forth in the health care plan; or (b) If the managed care organization submits the adverse determination to the external review organization without requiring the insured to exhaust all procedures set forth in the health care plan for reviewing the adverse determination within the managed care organization. (Added to NRS by 2003, 780) NRS 695G.251 Request for review; assignment of external review organization; provision of documents relating to adverse determination to external review organization. 1. If an insured or a physician of an insured receives notice of a final adverse determination from a managed care organization concerning the insured, and if the insured is required to pay $500 or more for the health care services that are the subject of the final adverse determination, the insured, the physician of the insured or an authorized representative may, within 60 days after receiving notice of the final adverse determination, submit a request to the managed care organization for an external review of the final adverse determination. 2. Within 5 days after receiving a request pursuant to subsection 1, the managed care organization shall notify the insured, his authorized representative or his physician, the agent who performed utilization review for the managed care organization, if any, and the Office for Consumer Health Assistance that the request has been filed with the managed care organization. 3. As soon as practicable after receiving a notice pursuant to subsection 2, the Office for Consumer Health Assistance shall assign an external review organization from the list maintained pursuant to NRS 683A.371. Each assignment made pursuant to this subsection must be completed on a rotating basis. 4. Within 5 days after receiving notification from the Office for Consumer Health Assistance specifying the external review organization assigned pursuant to subsection 3, the managed care organization shall provide to the external review organization all documents and materials relating to the final adverse determination, including, without limitation: (a) Any medical records of the insured relating to the external review; (b) A copy of the provisions of the health care plan upon which the final adverse determination was based; (c) Any documents used by the managed care organization to make the final adverse determination; (d) The reasons for the final adverse determination; and (e) Insofar as practicable, a list that specifies each provider of health care who has provided health care to the insured and the medical records of the provider of health care relating to the external review. (Added to NRS by 2003, 780) NRS 695G.261 Review of documents by external review organization; decision of external review organization. 1. Except as otherwise provided in NRS 695G.271, upon receipt of a request for an external review pursuant to NRS 695G.251, the external review organization shall, within 5 days after receiving the request: (a) Review the request and the documents and materials submitted pursuant to NRS 695G.251; and (b) Notify the insured, his physician and the managed care organization if any additional information is required to conduct a review of the final adverse determination. 2. Except as otherwise provided in NRS 695G.271, the external review organization shall approve, modify or reverse the final adverse determination within 15 days after it receives the information required to make that determination pursuant to this section. The external review organization shall submit a copy of its determination, including the reasons therefor, to: (a) The insured; (b) The physician of the insured; (c) The authorized representative of the insured, if any; and (d) The managed care organization. (Added to NRS by 2003, 781) NRS 695G.271 Expedited approval or denial of request. 1. A managed care organization shall approve or deny a request for an external review of a final adverse determination in an expedited manner not later than 72 hours after it 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. 2. If a managed care organization approves a request for an external review pursuant to subsection 1, the managed care organization shall: (a) In accordance with subsections 4 and 5, assign the request to an external review organization not later than 1 working day after approving the request; and (b) At the time of assigning the request, provide to the external review organization all documents and materials specified in subsection 4 of NRS 695G.251. 3. An external review organization that is assigned to conduct an external review pursuant to subsection 2 shall, if it accepts the assignment: (a) Complete its external review not later than 2 working days after receiving the assignment, unless the insured and the managed care organization agree to a longer period; (b) Not later than 1 working day after completing its external review, notify the insured, the physician of the insured, the authorized representative of the insured, if any, and the managed care organization by telephone of its determination; and (c) Not later than 5 working days after completing its external review, submit a written decision of its external review to the insured, the physician of the insured, the authorized representative of the insured, if any, and the managed care organization. 4. At least once each month, the Office for Consumer Health Assistance shall designate at least 2 external review organizations to conduct external reviews in an expedited manner pursuant to this section. As soon as practicable after designating an external review organization pursuant to this section, the Office for Consumer Health Assistance shall notify each managed care organization of the designation. 5. As soon as practicable after assigning an external review organization to conduct an external review pursuant to this section, the managed care organization shall notify the Office for Consumer Health Assistance of the assignment. Each assignment made by a managed care organization pursuant to this section must be completed on a rotating basis. (Added to NRS by 2003, 781) NRS 695G.280 Basis for decision of external review organization. The decision of an external review organization concerning a request for an external review must be based on: 1. Documentary evidence, including any recommendation of the physician of the insured submitted pursuant to NRS 695G.251; 2. Medical evidence, including, without limitation: (a) Professional standards of safety and effectiveness for diagnosis, care and treatment that are generally recognized in the United States; (b) Any report published in literature that is peer-reviewed; (c) Evidence-based medicine, including, without limitation, reports and guidelines that are published by professional organizations that are recognized nationally and that include supporting scientific data; and (d) An opinion of an independent physician who, as determined by the external review organization, is an expert in the health specialty that is the subject of the external review; and 3. The terms and conditions for benefits set forth in the evidence of coverage issued to the insured by the managed care organization.

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