(Added to NRS by 2003, 782) NRS 695G.290 Decision in favor of insured binding on managed care organization; limitation of liability; cost for external review organization. 1. If the determination of an external review organization concerning an external review of a final adverse determination is in favor of the insured, the determination is final, conclusive and binding upon the managed care organization. 2. An external review organization or any clinical peer who conducts or participates in an external review of a final adverse determination for the external review organization is not liable in a civil action for damages relating to a determination made by the external review organization if the determination is made in good faith and without gross negligence. 3. The cost of conducting an external review of a final adverse determination pursuant to NRS 695G.241 to 695G.310, inclusive, must be paid by the managed care organization that made the final adverse determination. (Added to NRS by 2003, 782) NRS 695G.300 Submission of complaint of insured to external review organization. In lieu of resolving a complaint of an insured in accordance with a system for resolving complaints established pursuant to the provisions of NRS 695G.200, a managed care organization may: 1. Submit the complaint to an external review organization pursuant to the provisions of NRS 695G.241 to 695G.310, inclusive; or 2. If a federal law or regulation provides a procedure for submitting the complaint for resolution that the Commissioner determines is substantially similar to the procedure for submitting the complaint to an external review organization pursuant to NRS 695G.241 to 695G.310, inclusive, submit the complaint for resolution in accordance with the federal law or regulation. (Added to NRS by 2003, 782) NRS 695G.310 Annual report; requirements. On or before December 31 of each year, each managed care organization shall file a written report with the Office for Consumer Health Assistance setting forth the total number of: 1. Requests for external review that were received by the managed care organization during the immediately preceding year; and 2. Final adverse determinations of the managed care organization that were: (a) Upheld during the immediately preceding year. (b) Reversed during the immediately preceding year. (Added to NRS by 2003, 783; A 2005, 1026) PROHIBITED ACTS NRS 695G.400 Managed care organization prohibited from interfering in or restricting certain communications. A managed care organization shall not restrict or interfere with any communication between a provider of health care and his patient regarding any information that the provider of health care determines is relevant to the health care of the patient. (Added to NRS by 1997, 304)—(Substituted in revision for NRS 659G.240) 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.] 1. Except as otherwise provided in subsection 2, a managed care organization shall not: (a) Deny a claim under a health care plan solely because the claim involves an injury sustained by an insured as a consequence of being intoxicated or under the influence of a controlled substance. (b) Cancel participation under a health care plan solely because an insured has made a claim involving an injury sustained by the insured as a consequence of being intoxicated or under the influence of a controlled substance. (c) Refuse participation under a health care plan to an eligible applicant solely because the applicant has made a claim involving an injury sustained by the applicant as a consequence of being intoxicated or under the influence of a controlled substance. 2. The provisions of this section do not prohibit a managed care organization from enforcing a provision included in a health care plan to: (a) Deny a claim which involves an injury to which a contributing cause was the insured’s commission of or attempt to commit a felony; (b) Cancel participation under a health care plan solely because of such a claim; or (c) Refuse participation under a health care plan to an eligible applicant solely because of such a claim. (Added to NRS by 2005, 2347, 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. A managed care organization shall not terminate a contract with, demote, refuse to contract with or refuse to compensate a provider of health care solely because the provider, in good faith: 1. Advocates in private or in public on behalf of a patient; 2. Assists a patient in seeking reconsideration of a decision by the managed care organization to deny coverage for a health care service; or 3. Reports a violation of law to an appropriate authority. (Added to NRS by 1997, 304)—(Substituted in revision for NRS 659G.250) NRS 695G.420 Offering or paying financial incentive to provider to deny, reduce, withhold, limit or delay medically necessary services prohibited. 1. A managed care organization shall not offer or pay any type of material inducement, bonus or other financial incentive to a provider of health care to deny, reduce, withhold, limit or delay specific medically necessary health care services to an insured. 2. Nothing in this section prohibits an arrangement for payment between a managed care organization and a provider of health care that uses capitation or other financial incentives, if the arrangement is designed to provide an incentive to the provider of health care to use health care services effectively and consistently in the best interest of the health care of the insured. (Added to NRS by 1997, 304)—(Substituted in revision for NRS 659G.260) 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. 1. A managed care organization shall not contract with a provider of health care to provide health care to an insured unless the managed care organization uses the form prescribed by the Commissioner pursuant to NRS 629.095 to obtain any information related to the credentials of the provider of health care. 2. A contract between a managed care organization and a provider of health care may be modified: (a) At any time pursuant to a written agreement executed by both parties. (b) Except as otherwise provided in this paragraph, by the managed care organization upon giving to the provider 30 days’ written notice of the modification. If the provider fails to object in writing to the modification within the 30-day period, the modification becomes effective at the end of that period. If the provider objects in writing to the modification within the 30-day period, the modification must not become effective unless agreed to by both parties as described in paragraph (a). 3. If a managed care organization contracts with a provider of health care to provide health care services pursuant to chapter 689A, 689B, 689C, 695A, 695B or 695C of NRS, the managed care organization shall: (a) If requested by the provider of health care at the time the contract is made, submit to the provider of health care the schedule of payments applicable to the provider of health care; or (b) If requested by the provider of health care at any other time, submit to the provider of health care the schedule of payments specified in paragraph (a) within 7 days after receiving the request. 4. As used in this section, “provider of health care” means a provider of health care who is licensed pursuant to chapter 630, 631, 632 or

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