NAC695F.610. Requirements for approval.

To obtain approval of a system for resolving complaints of enrollees concerning limited health services covered by an organization from the Commissioner as required pursuant to NAC 695F.600, an organization must:

     1. Demonstrate that the system will resolve oral and written complaints concerning:

     (a) Payment or reimbursement for covered limited health services;

     (b) The availability, delivery or quality of covered limited health services, including, without limitation, adverse determinations made pursuant to utilization review; and

     (c) The terms and conditions of the evidences of coverage of enrollees.

     2. If the organization issues any evidence of coverage that provides, delivers, arranges for, pays for or reimburses any cost of health care services through managed care, demonstrate that the system will include the external review of a final adverse determination.

     3. Submit to the Division:

     (a) The name and title of the employee responsible for the system;

     (b) A description of the procedure used to notify an enrollee of the decision regarding his or her complaint; and

     (c) A copy of the explanation of rights and procedures which is to be provided to enrollees pursuant to NAC 695F.620.

     (Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99; A by R132-03, 4-16-2004)