NAC695C.025. “Delivery system intermediary” defined.

     1. “Delivery system intermediary” means a partnership, association, corporation or other legal entity which enters into a contract with an organization to provide health care services. The term includes:

     (a) An entity jointly owned and controlled by a hospital and a physician; and

     (b) An entity primarily owned and controlled by physicians.

     2. The term does not include:

     (a) A provider who enters into a contract with an organization to provide health care services, if that provider furnishes those services directly to enrollees.

     (b) A group practice, if the group practice primarily uses only its employees, partners or shareholders to provide health care services.

     (c) An organization.

     (d) A prepaid limited health service organization.

     (e) A provider or entity whose contract with an organization provides that:

          (1) The organization assumes financial responsibility for any claims presented for payment to the provider or entity by a provider for covered health care services furnished to a subscriber or an enrollee if those claims are not paid by the provider or entity as provided by law or by the contract between the provider and the organization;

          (2) The organization retains the premiums paid and the responsibility for the payment of claims presented;

          (3) All denials for health care services remain the responsibility of the organization; and

          (4) The organization maintains the appropriate amount of reinsurance.

     (Added to NAC by Comm’r of Insurance by R129-96, eff. 10-29-97)