NAC287.660. Notification of adverse determination; grounds for appeal.

     1. The Claims Administrator shall notify a participant of an adverse determination of a claim of the participant or his or her dependent. Such notification must:

     (a) Be in writing;

     (b) Explain the reason for the adverse determination;

     (c) Include the specific provision of the applicable plan of the Program used by the Claims Administrator as the basis for the adverse determination;

     (d) If the adverse determination is made as a result of a lack of information, request any additional information necessary to reverse the adverse determination; and

     (e) Explain the process for initiating an appeal of the adverse determination pursuant to NAC 287.670.

     2. A participant may appeal an adverse determination if the participant feels the claim was not adjudicated pursuant to the current terms and conditions of 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; R016-08, 8-26-2008, eff. 7-1-2009; R002-12, 6-29-2012)