AB52 - Revises provisions relating to the payment of claims under policies of health insurance. (BDR 57-367)

- 83rd Session (2025) Assembly Bill No. 52–Committee on Commerce and Labor CHAPTER.......... AN ACT relating to insurance; requiring the Commissioner of Insurance to establish programs to inform providers of health care and insureds under health insurance policies of certain information relating to the payment of claims; revising provisions governing the payment of claims under policies of health insurance; establishing certain administrative penalties; requiring a health carrier to provide certain information to participating providers of health care and covered persons; requiring a health carrier to establish certain procedures for challenging the denial of a claim; and providing other matters properly relating thereto. Legislative Counsel’s Digest: In most cases, existing law requires the administrators of health insurance plans and certain health insurers to approve or deny a claim within 30 days after the insurer receives the claim. If the administrator or insurer approves the claim, existing law requires the administrator or insurer to pay the claim within 30 days after the claim is approved. If the administrator or insurer requires additional information to determine whether to approve or deny the claim, existing law requires the administrator or insurer to notify the claimant of its request for additional information within 20 days after the administrator or insurer receives the claim. If the administrator or insurer approves the claim after receiving such additional information from the claimant, existing law requires the administrator or insurer to pay the claim within 30 days after receiving such information. Existing law requires an administrator or insurer that fails to pay a claim within the required time period to pay interest on the claim at a prescribed rate. (NRS 287.04335, 683A.0879, 689A.410, 689B.255, 689C.335, 695A.188, 695B.2505, 695C.185, 695D.215, 695F.090) Sections 2, 5, 8-11, 14 and 16 of this bill replace those requirements with uniform requirements governing the time periods for the payment of health insurance claims that apply to administrators of health insurance plans and all private health insurers in this State. Specifically, sections 2, 5, 8-11, 14 and 16 require each such administrator or insurer to approve or deny a claim and, if the claim is approved, pay the claim within: (1) twenty-one days after receiving the claim, if the claim is submitted electronically; or (2) thirty days after receiving the claim, if the claim is not submitted electronically. Sections 2, 5, 8-11, 14 and 16 require an administrator or insurer that needs additional information to determine whether to approve or deny a claim to request such information within 20 working days after receiving the claim. If, after receiving such additional information, the administrator or insurer approves the claim, sections 2, 5, 8-11, 14 and 16 require the administrator or insurer, as applicable, to pay the claim within: (1) twenty-one days after receiving the additional information, if the additional information is submitted electronically; or (2) thirty days after receiving the additional information, if the additional information is not submitted electronically. Sections 2, 5, 8-11, 14 and 16 prohibit an administrator or insurer from denying a claim without a reasonable basis for doing so. Sections 2, 5, 8-11, 14 and 16 require an administrator or insurer to annually report to the Commissioner of – 2 – - 83rd Session (2025) Insurance certain information relating to compliance with those requirements. Section 25 of this bill repeals certain provisions applicable to health maintenance organizations that are no longer necessary because existing law makes the provisions of section 16 applicable to all managed care organizations, including health maintenance organizations. (NRS 695C.055) Sections 13 and 18 of this bill update references to a section repealed by section 25 with a reference to section 16. Existing law authorizes the Commissioner to: (1) impose an administrative penalty upon determining that the administrator of a health insurance plan or certain health insurers are not in substantial compliance with the provisions of existing law governing the schedule for paying claims; and (2) suspend or revoke the certificate of registration or authority of such an administrator or insurer upon a second or subsequent determination that such an administrator or insurer is not in substantial compliance with those provisions. (NRS 287.04335, 683A.0879, 689A.410, 689B.255, 689C.335, 695B.2505, 695C.185, 695F.090) Sections 10, 14 and 16 of this bill extend those penalties to apply to fraternal benefit societies, issuers of plans for dental care and managed care organizations. Sections 2, 5, 8-11, 14 and 16 additionally authorize the Commissioner to: (1) impose an administrative penalty upon determining that the administrator of a health insurance plan or a health insurer has failed to approve or deny a claim or pay an approved claim within 60 working days after receiving the claim; and (2) suspend or revoke the certificate of registration or authority of an administrator or insurer upon a second or subsequent such determination. Existing law requires certain health insurers to provide certain notice to an insured within 10 days after denying coverage. (NRS 689A.755, 689B.0295, 695B.400, 695G.230) Sections 2, 6, 7, 9, 10, 12, 14, 15 and 18 of this bill require health insurers and administrators of health insurance plans to provide notice of the denial of a claim within 21 days after receiving all information necessary to make a determination concerning the claim if the information is submitted electronically, or if the information is not received electronically, within 30 days after receiving the necessary information. Sections 2, 6, 7, 9, 10, 12, 14, 15 and 18 also require the inclusion of certain additional information in such a notice. Sections 10, 14 and 16 make certain other provisions relating to the payment of claims that currently apply to most health insurers also apply to fraternal benefit societies, organizations for dental care and managed care organizations so that the requirements governing the payment of claims are uniform for all health insurers. Sections 2, 12.5, 17.5 and 18.5 of this bill exempt coverage under Medicaid, the Children’s Health Insurance Program and the Public Employees’ Benefits Program from the requirements of sections 2, 8, 13, 16 and 18. Existing law requires a health carrier which offers or issues a network plan to notify each participating provider of health care in the network of the responsibilities of the provider of health care with respect to any applicable administrative policies and programs of the health carrier. (NRS 687B.730) Section 3 of this bill additionally requires such a health carrier to provide to each participating provider of health care and each covered person at least annually an explanation of the process by which the health carrier will provide remittances to or pay claims submitted by participating providers of health care. Section 3 exempts coverage by managed care organizations under Medicaid, the Children’s Health Insurance Program and the Public Employees’ Benefits Program from all such notification requirements. Existing law requires a health carrier which offers or issues a network plan to establish procedures for the resolution of disputes between the health carrier and a participating provider of health care. (NRS 687B.820) Section 4 of this bill requires those procedures to include an efficient process by which a participating provider – 3 – - 83rd Session (2025) of health care may challenge the denial by a health carrier of a claim. Section 4 exempts coverage by managed care organizations under Medicaid, the Children’s Health Insurance Program and the Public Employees’ Benefits Program from the requirement to establish such procedures. Section 1 of this bill requires the Division of Insurance of the Department of Business and Industry to establish and carry out certain programs to facilitate public knowledge and use of the provisions of this bill. EXPLANATION – Matter in bolded italics is new; matter between brackets [omitted material] is material to be omitted. WHEREAS, Ensuring timely reimbursement for providers of health care will enhance the business environment in this State for providers of health care and improve access to health care for residents of this State; and WHEREAS, Prompt payment of claims by health insurers will create a more stable and attractive landscape for new medical practices, thereby improving the health care infrastructure of this State; and WHEREAS, Delayed payments by insurers have a disproportionate negative effect on minority communities, whose residents are less likely to have the means to pay out of pocket for health care services; now, therefore, THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS: Section 1. NRS 679B.550 is hereby amended to read as follows: 679B.550 The Division shall: 1. Establish a toll-free telephone service for receiving inquiries and complaints from consumers of health care in this State concerning health care plans; 2. Provide answers to inquiries of consumers of health care concerning health care plans, or refer the consumers to the appropriate agency, department or other entity that is responsible for addressing the specific type of inquiry; 3. Refer consumers of health care to the appropriate agency, department or other entity that is responsible for addressing the specific type of complaint of the consumer; 4. Provide counseling and assistance to consumers of health care concerning health care plans; 5. Educate consumers of health care concerning health care plans in this State; [and] 6. Establish and carry out: – 4 – - 83rd Session (2025) (a) A campaign to inform providers of health care and insureds of the provisions of NRS 683A.0879, 687B.730, 687B.820, 689A.410, 689A.755, 689B.0295, 689B.255, 689C.335, 695A.188, 695B.2505, 695B.400, 695D.215 and 695G.230 and sections 15 and 16 of this act; and (b) A program to provide additional support and resources to assist providers of health care who operate small health care practices or are new to operating a health care practice in: (1) Navigating the process for seeking reimbursement from insurers; and (2) Ensuring that insurers comply with the requirements of NRS 683A.0879, 687B.730, 687B.820, 689A.410, 689A.755, 689B.0295, 689B.255, 689C.335, 695A.188, 695B.2505, 695B.400, 695D.215 and 695G.230 and sections 15 and 16 of this act; and 7. Take such actions as are necessary to ensure public awareness of the existence and purpose of the services provided by the Division pursuant to this section. Sec. 2. NRS 683A.0879 is hereby amended to read as follows: 683A.0879 1. Except as otherwise provided in subsection [2] 3 and NRS 439B.754, an administrator shall approve or deny a claim relating to health insurance coverage and, if the administrator: (a) Approves the claim, pay the claim within [30] : (1) Twenty-one days after the administrator receives the claim [. If the claim is approved, the administrator shall pay the claim within 30 days after it is approved.] , if the claim is submitted electronically; or (2) Thirty days after the administrator receives the claim, if the claim is not submitted electronically. (b) Denies the claim, notify the claimant in writing of the denial within 21 days after the administrator receives the claim, if the claim is submitted electronically, or 30 days after the administrator receives the claim, if the claim is not submitted electronically. The notice must include, without limitation: (1) All reasons for denying the claim, including, without limitation, the specific facts and provisions of the policy relied upon by the administrator as a basis to deny the claim; (2) The criteria by which the administrator determines whether to approve or deny the claim and a description of the manner in which the administrator applied those criteria to the claim; and (3) A summary of any applicable process established pursuant to NRS 687B.820 for challenging the denial of the claim. – 5 – - 83rd Session (2025) 2. Except as otherwise provided in this section, if the approved claim is not paid within [that] the period [,] specified in subsection 1, the administrator shall pay interest on the claim at a rate of [interest equal to the prime rate at the largest bank in Nevada, as ascertained by the Commissioner of Financial Institutions, on January 1 or July 1, as the case may be, immediately preceding the date on which the payment was due, plus 6] 10 percent [.] per annum. The interest must be calculated from [30 days after] the date on which payment of the claim is [approved] due pursuant to subsection 1 until the date on which the claim is paid. [2.] 3. If the administrator requires additional information to determine whether to approve or deny the claim, the administrator shall notify the claimant of the administrator’s request for the additional information within 20 working days after receiving the claim. The administrator shall notify the [provider of health care] claimant of all the specific reasons for the delay in approving or denying the claim. The administrator shall approve or deny the claim and, if the administrator: (a) Approves the claim, pay the claim within [30] : (1) Twenty-one days after receiving the additional information, if the information is submitted electronically; or (2) Thirty days after receiving the additional information [. If the claim is approved, the administrator shall pay the claim within 30 days after receiving the additional information.] , if the information is not submitted electronically. (b) Denies the claim, provide notice of the denial in the manner prescribed in paragraph (b) of subsection 1 within 21 days after receiving the additional information, if the information is submitted electronically, or 30 days after receiving the additional information, if the information is not submitted electronically. 4. If [the] a claim approved [claim] pursuant to subsection 3 is not paid within [that] the period [,] specified in that subsection, the administrator shall pay interest on the claim in the manner prescribed in subsection [1.] 2. [3.] 5. An administrator shall not [request] : (a) Deny a claim relating to health insurance coverage without a reasonable basis for the denial. (b) Request a claimant to resubmit information that the claimant [Text truncated for display. Full text available on LegiScan.]