NAC287.670. Appeal of adverse determination: Requirements; duties of Appeals Manager.

     1. Except as otherwise provided in NAC 287.695, to initiate an appeal of an adverse determination of a claim, a participant must submit a written request to the Claims Administrator within 180 days after the date on which the participant received the notification of the adverse determination that is required pursuant to NAC 287.660. A request for an appeal of an adverse determination must include:

     (a) The name of the participant;

     (b) The social security number or member identification number of the participant;

     (c) A copy of the explanation of benefits related to the claim that was provided to the participant by the Claims Administrator;

     (d) A copy of the claim that was submitted to the Claims Administrator from the vendor; and

     (e) A statement setting forth the reasons the adverse determination is being appealed.

     2. The Appeals Manager of the Claims Administrator shall:

     (a) Review the appeal of an adverse determination to decide if the claim was adjudicated pursuant to the:

          (1) Current terms and conditions of the Program; and

          (2) Contract between the Program and applicable vendor; and

     (b) Within 20 days after receiving the request for an appeal, advise the participant in writing of:

          (1) The decision of the Appeals Manager, setting forth the reasons therefor;

          (2) The specific provision of the applicable plan of the Program used by the Appeals Manager as the basis for the decision; and

          (3) The process by which the participant may appeal the decision of the Appeals Manager pursuant to NAC 287.680.

     3. As used in this section, “member identification number” means the number assigned to a participant by the Program.

     (Added to NAC by Com. on Group Ins., eff. 3-9-88; A by Bd. of Pub. Employees’ Benefits Prog. by R126-00, 12-22-2000, eff. 1-1-2001; R154-03, 3-22-2004; R126-07, 1-30-2008; R016-08, 8-26-2008, eff. 7-1-2009; R002-12, 6-29-2012)