NAC695F.620. Notices: Right of member to file complaint; denial of coverage; clear and comprehensive language.

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

     (a) At the time he or she receives the evidence of coverage;

     (b) Any time that the organization denies coverage of a limited health service or limits coverage of a limited health service to an enrollee; and

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

     2. If an organization denies coverage of a limited health service to an enrollee, it shall notify the enrollee in writing of:

     (a) The reason for denying coverage of the limited health service;

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

     (c) The right to file a written complaint and the procedure for filing such a complaint;

     (d) 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, the right to:

          (1) Appeal a final adverse determination pursuant to NRS 695G.200 to 695G.310, inclusive;

          (2) Receive an expedited external review of a final adverse determination if the managed care organization receives proof from the insured’s provider of health care that failure to proceed in an expedited manner may jeopardize the life or health of the insured, including notification of the procedure for requesting the expedited external review; and

          (3) Receive assistance from any person, including an attorney, for an external review of a final adverse determination; and

     (e) The telephone number of the Office for Consumer Health Assistance.

     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; A by R132-03, 4-16-2004)