NAC695D.520. Notices: Right of member to file complaint; denial of coverage; clear and comprehensible language.

     1. Following approval by the Commissioner, each organization that issues a policy in this State shall provide written notice to a member, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the member to file a written complaint. Such notice must be provided to a member:

     (a) At the time he or she receives the policy;

     (b) Any time that the organization denies coverage of a service or limits coverage of a service to a member; and

     (c) Any other time deemed necessary by the Commissioner.

     2. Any time that an organization denies coverage of a service to a member, it shall notify the member in writing of:

     (a) The reasons for denying the coverage of the service;

     (b) The criteria by which the organization determines whether to authorize or deny coverage of the service; and

     (c) The right to file a written complaint.

     3. A written notice which is approved by the Commissioner shall be deemed to be in clear and comprehensible language that is understandable to an ordinary layperson.

     (Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)