AB202 - Revises provisions relating to claims for dental care. (BDR 57-573)

- 83rd Session (2025) Assembly Bill No. 202–Assemblymember Brown-May CHAPTER.......... AN ACT relating to insurance; revising certain definitions for the purposes of certain coverage for health care services; revising provisions governing the circumstances under which a managed care organization is not required to authorize coverage of a health care service; revising the applicability of certain provisions requiring certain insurers to establish a system of procedures for resolving complaints of insured persons and providing for the external review of an adverse determination to include certain insurers that issue policies or certificates that provide only dental coverage; revising the information which a health carrier is required to provide in a notice of an adverse determination; authorizing a dentist of a covered person to submit to the Office for Consumer Health Assistance in the Department of Health and Human Services a request for an external review of an adverse determination; requiring an independent review organization to notify the dentist of a covered person and a health carrier of certain information and the determination and reasons of the independent review organization; requiring a decision of an independent review organization to be based, in part, on certain documentary evidence, including any recommendation of the dentist of the insured; and providing other matters properly relating thereto. Legislative Counsel’s Digest: Existing law requires each managed care organization to authorize coverage of a health care service that has been recommended for an insured by a provider of health care acting within the scope of his or her practice if that service is covered by the health care plan of the insured unless the decision not to authorize coverage is made by a physician who satisfies certain conditions. (NRS 695G.150) Section 2 of this bill provides that a managed care organization is also not required to authorize coverage if the decision not to authorize coverage is made by a dentist who satisfies certain conditions. Existing law: (1) requires a managed care organization to establish a system of procedures for resolving complaints of a person who is insured by a managed care organization; and (2) provides for the external review of an adverse determination by a managed care organization. (NRS 695G.200-695G.310) The requirement for the establishment of a system of procedures for resolving complaints and the provisions setting forth procedures for the external review of an adverse determination also apply to insurers that issue certain policies, plans, contracts and coverage for health insurance in this State that provide, deliver, arrange for, pay for or reimburse costs of health care through managed care, including: (1) certain health insurance provided through a plan of self-insurance for officers and employees of this State; (2) individual health insurance; (3) group health insurance; (4) health benefit plans of small employers; (5) contracts for hospital or medical – 2 – - 83rd Session (2025) services; (6) health care plans issued by health maintenance organizations; and (7) evidence of coverage issued by prepaid limited health service organizations. (NRS 287.04335, 689A.745, 689B.0285, 689C.156, 695B.380, 695C.260, 695F.230) Existing law exempts a policy or certificate that provides only dental coverage from these provisions. (NRS 695G.243) Section 3 of this bill provides that the requirement for the establishment of a system of procedures for resolving complaints and the provisions setting forth procedures for the external review of an adverse determination apply to a policy or certificate that provides only dental coverage. Existing law requires a health carrier to notify certain persons, including a covered person and his or her treating physician, of: (1) an adverse determination relating to a request for the provision of or payment for a health care service or course of treatment; and (2) certain information which must be included in such a notice, including the ability to file a request for an expedited external review if, among other conditions, the insured’s treating physician makes certain written certifications relating to the recommended or requested health care service or treatment. (NRS 695G.245) Section 4 of this bill provides that a dentist may make the required written certifications. Existing law authorizes a covered person, a physician of a covered person or an authorized representative to submit a request to the Office for Consumer Health Assistance in the Department of Health and Human Services for an external review of an adverse determination. (NRS 695G.251) Section 5 of this bill authorizes a dentist of a covered person to submit such a request. Existing law requires an independent review organization that receives a request for an external review to: (1) notify the covered person, the physician of the covered person and the health carrier if any additional information is required to conduct the review; (2) forward to the health carrier any information received from a covered person or the physician of a covered person; and (3) notify the covered person, the physician of the covered person, the authorized representative of the covered person and the health carrier of its determination and reasons therefor. (NRS 695G.261) Section 6 of this bill requires the independent review organization to also: (1) notify the dentist of the covered person if any additional information is required to conduct the review; (2) forward to the health carrier any information received from the dentist of a covered person; and (3) notify the dentist of the covered person of its determination and reasons therefor. Existing law requires an independent review organization to notify a covered person, the physician of the covered person, the authorized representative, if any, and the health carrier by telephone and in writing after completing its external review. (NRS 695G.271) Section 7 of this bill requires an independent review organization to notify the dentist of a covered person, if applicable. Existing law sets forth the process by which an external review of an adverse determination must be conducted. (NRS 695G.275) Section 8 of this bill revises provisions setting forth that process to provide a covered person’s treating dentist with the same powers and duties with respect to that process as a covered person’s treating physician. Existing law requires the decision of an independent review organization concerning a request for an external review to be based, in part, on documentary evidence, including any recommendation of the physician of the insured. (NRS 695G.280) Section 9 of this bill requires that documentary evidence to include any recommendation of the dentist of the insured. Existing law provides a clinical peer who conducts or participates in an external review of an adverse determination immunity from liability for certain damages relating to the external review under certain circumstances. (NRS 695G.290) – 3 – - 83rd Session (2025) Section 1 of this bill revises the definition of “clinical peer” to include certain dentists. EXPLANATION – Matter in bolded italics is new; matter between brackets [omitted material] is material to be omitted. THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS: Section 1. NRS 695G.016 is hereby amended to read as follows: 695G.016 “Clinical peer” means [a] : 1. A physician who is: [1.] (a) Engaged in the practice of medicine; and [2.] (b) Certified or is eligible for certification by a member board of the American Board of Medical Specialties in the same or similar area of practice as is the health care service that is the subject of a final adverse determination [.] ; or 2. A dentist who is: (a) Licensed by the Board of Dental Examiners of Nevada pursuant to chapter 631 of NRS; and (b) Engaged in the practice of dentistry. Sec. 2. NRS 695G.150 is hereby amended to read as follows: 695G.150 Each managed care organization shall authorize coverage of a health care service that has been recommended for the insured by a provider of health care acting within the scope of his or her practice if that service is covered by the health care plan of the insured, unless: 1. The decision not to authorize coverage is made by a physician or dentist who: (a) Is licensed to practice medicine or dentistry in the State of Nevada pursuant to chapter 630 , 631 or 633 of NRS; (b) Possesses the education, training and expertise to evaluate the medical condition of the insured; and (c) Has reviewed the available medical documentation, notes of the attending physician [,] or dentist, test results and other relevant medical records of the insured.  The physician or dentist may consult with other providers of health care in determining whether to authorize coverage. 2. The decision not to authorize coverage and the reason for the decision have been transmitted in writing in a timely manner to the insured, the provider of health care who recommended the service and the primary care physician or dentist of the insured, if any. – 4 – - 83rd Session (2025) Sec. 3. NRS 695G.243 is hereby amended to read as follows: 695G.243 1. Except as otherwise provided in subsection 2, the provisions of NRS 695G.200 to 695G.310, inclusive, apply to all health carriers. 2. The provisions of subsection 1 do not apply to: (a) A policy or certificate that provides only coverage for: (1) A specified disease or accident; (2) Accidents; (3) Credit; (4) [Dental; (5)] Disability income; [(6)] (5) Hospital indemnity; [(7)] (6) Long-term care insurance; [(8)] (7) Vision care; or [(9)] (8) Any other limited supplemental benefit; (b) A Medicare supplement policy of insurance, as defined in regulations adopted by the Commissioner; (c) Coverage under a plan through Medicare, Medicaid or the Federal Employees Health Benefits Program, FEHBP, 5 U.S.C. §§ 8901 et seq.; (d) Any coverage issued under the Civilian Health and Medical Program of the Uniformed Services, CHAMPUS, 10 U.S.C. §§ 1071 et seq., and any coverage issued as supplemental to that coverage; (e) Any coverage issued as supplemental to liability insurance; (f) Workers’ compensation or similar insurance; (g) Automobile medical payment insurance; or (h) Any insurance under which benefits are payable with or without regard to fault, whether written on a group, blanket or individual basis. Sec. 4. NRS 695G.245 is hereby amended to read as follows: 695G.245 1. A health carrier shall notify the covered person in writing of the covered person’s right to request an external review to be conducted pursuant to NRS 695G.241 to 695G.310, inclusive, and include the appropriate statements and information set forth in subsection 2 at the same time the health carrier sends written notice of an adverse determination upon completion of the health carrier’s utilization review process set forth in NRS 683A.375 to 683A.379, inclusive, and the regulations adopted pursuant thereto. 2. As part of the written notice required pursuant to subsection 1, a health carrier shall include the following, or substantially equivalent, language: – 5 – - 83rd Session (2025) We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested by submitting a request for external review to the Office for Consumer Health Assistance. 3. The Commissioner may prescribe by regulation the form and content of the notice required pursuant to this section. 4. The health carrier shall include in the notice required pursuant to subsection 1 a statement informing the covered person that: (a) If the covered person has a medical condition where the time frame for completion of an expedited review of a grievance involving an adverse determination set forth in NRS 695G.200 to 695G.230, inclusive, would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, the covered person or the covered person’s authorized representative may, at the same time the covered person or the covered person’s authorized representative files a request for an expedited review of a grievance involving an adverse determination as set forth in NRS 695G.210, file a request for an expedited external review to be conducted pursuant to NRS 695G.271 and 695G.275 if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person’s treating physician or dentist, as applicable, certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated, and the independent review organization assigned to conduct the expedited external review will determine whether the covered person will be required to complete the expedited review of the grievance before conducting the expedited external review; and (b) The covered person or the covered person’s authorized representative may file a grievance under the health carrier’s internal grievance process as set forth in NRS 695G.200 to 695G.230, inclusive, but if the health carrier has not issued a written decision to the covered person or the covered person’s authorized – 6 – - 83rd Session (2025) representative within 30 days after the date on which the covered person or the covered person’s authorized representative filed the grievance with the health carrier and the covered person or the covered person’s authorized representative has not requested or agreed to a delay, the covered person or the covered person’s authorized representative may file a request for external review pursuant to NRS 695G.251 and shall be considered to have exhausted the health carrier’s internal grievance process. 5. In addition to the information required to be provided pursuant to subsection 1, the health carrier shall include a copy of the description of both the standard and expedited external review procedures the health carrier is requir [Text truncated for display. Full text available on LegiScan.]