NAC287.680. Appeal of decision of Appeals Manager: Requirements; duties of Executive Officer or designee.

     1. Except as otherwise provided in NAC 287.695, if a participant in the Program is unsatisfied with the decision of the Appeals Manager made pursuant to NAC 287.670, the participant may file an appeal with the Executive Officer or a designee thereof. Such an appeal must be in writing and be filed within 35 days after the participant’s receipt of the decision of the Appeals Manager. Such an appeal must include all supporting documentation, including, without limitation, a copy of the request for an appeal of the adverse determination submitted to the Claims Administrator pursuant to NAC 287.670, a copy of the decision of the Appeals Manager concerning the adverse determination and any other information provided to the Claims Administrator by the participant.

     2. The Executive Officer or the designee shall:

     (a) Review the material submitted by the participant 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 30 days after receipt of the participant’s appeal, notify the participant in writing of:

          (1) The decision of the Executive Officer or the designee, setting forth the reasons therefor;

          (2) The specific provision of the applicable plan of the Program used by the Executive Officer or the designee as a basis for the decision; and

          (3) The process by which the participant may request an external review of the adverse determination pursuant to NAC 287.690.

     (Added to NAC by Com. on Group Ins., eff. 3-9-88; A by Com. on Benefits, 5-4-92; 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; R002-12, 6-29-2012)