695G.280 - Basis for decision of external review organization. - Nevada Statutes

695G.280  Basis for decision of external review organization.  The decision of an external review organization concerning a request for an external review must be based on:

      1.  Documentary evidence, including any recommendation of the physician of the insured submitted pursuant to NRS 695G.251;

      2.  Medical evidence, including, without limitation:

      (a) Professional standards of safety and effectiveness for diagnosis, care and treatment that are generally recognized in the United States;

      (b) Any report published in literature that is peer-reviewed;

      (c) Evidence-based medicine, including, without limitation, reports and guidelines that are published by professional organizations that are recognized nationally and that include supporting scientific data; and

      (d) An opinion of an independent physician who, as determined by the external review organization, is an expert in the health specialty that is the subject of the external review; and

      3.  The terms and conditions for benefits set forth in the evidence of coverage issued to the insured by the managed care organization.

      (Added to NRS by 2003, 782)