695G.160 - Written criteria concerning coverage of health care services and standards for quality of health care services. - Nevada Statutes

695G.160  Written criteria concerning coverage of health care services and standards for quality of health care services.

      1.  Each managed care organization shall establish written criteria:

      (a) Setting forth the manner in which it determines whether to authorize coverage of a health care service; and

      (b) Setting forth its method for reviewing standards for the quality of health care services provided to an insured.

      2.  Such written criteria must be:

      (a) Developed with the assistance of practicing providers of health care;

      (b) Developed using generally recognized and, if appropriate, specialized clinical principles and processes;

      (c) Reviewed at least one time each year and, if appropriate, updated; and

      (d) Made available to an insured for review upon request of the insured any time that the managed care organization denies coverage of a specific health care service to the insured.

      (Added to NRS by 1997, 302)