Senate Bill No. 99–Senator O’Connell (by request)
CHAPTER..........
AN ACT relating to insurance; revising provisions governing the prompt payment by insurers of approved claims to providers of health care; revising the rate of interest applicable to the late payment of such claims; prohibiting the assessment of fees against providers of health care to be included on a list of providers of health care; establishing an administrative fine against insurers who do not substantially comply with the provisions requiring prompt payment of approved claims to providers of health care; allowing an employee who is injured or who contracts an occupational disease outside this state to receive compensation from the uninsured employers’ claim fund under certain circumstances; and providing other matters properly relating thereto.
THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN
SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS:
1-1 Section 1. NRS 679B.138 is hereby amended to read as follows:
1-2 679B.138 1. The commissioner shall adopt regulations which require
1-3 the use of uniform claim forms and billing codes and the ability to make
1-4 compatible electronic data transfers for all insurers and administrators
1-5 authorized to conduct business in this state relating to a health care plan or
1-6 health insurance or providing or arranging for the provision of health care
1-7 services, including, without limitation, an insurer that issues a policy of
1-8 health insurance, an insurer that issues a policy of group health insurance,
1-9 a carrier serving small employers, a fraternal benefit society, a hospital or
1-10 medical service corporation, a health maintenance organization, a plan for
1-11 dental care and a prepaid limited health service organization. The
1-12 regulations must include, without limitation, a uniform billing format to
1-13 be used for the submission of claims to such insurers and
1-14 administrators.
1-15 2. As used in this section:
1-16 (a) “Administrator” has the meaning ascribed to it in NRS 683A.025.
1-17 (b) “Health care plan” means a policy, contract, certificate or agreement
1-18 offered or issued by an insurer to provide, deliver, arrange for, pay for or
1-19 reimburse any of the costs of health care services.
1-20 Sec. 1.5. NRS 683A.0879 is hereby amended to read as follows:
1-21 683A.0879 1. Except as otherwise provided in subsection 2, an
1-22 administrator shall approve or deny a claim relating to health insurance
1-23 coverage within 30 days after the administrator receives the claim. If the
1-24 claim is approved, the administrator shall pay the claim within 30 days
1-25 after it is approved. [If] Except as otherwise provided in this section, if
1-26 the approved claim is not paid within that period, the administrator shall
1-27 pay interest on the claim at [the] a rate of interest [established pursuant to
1-28 NRS 99.040 unless a different rate of interest is established pursuant to an
1-29 express written contract between the administrator and the provider of
1-30 health care.] equal to the prime rate at the largest bank in Nevada, as
1-31 ascertained by the commissioner of financial institutions, on January 1
1-32 or July 1, as the case may be, immediately preceding the date on which
1-33 the payment was due, plus 6 percent. The interest must be calculated from
1-34 30 days after the date on which the claim is approved until the date on
1-35 which the claim is paid.
1-36 2. If the administrator requires additional information to determine
1-37 whether to approve or deny the claim, he shall notify the claimant of his
2-1 request for the additional information within 20 days after he receives the
2-2 claim. The administrator shall notify the provider of health care of all the
2-3 specific reasons for the delay in approving or denying the claim. The
2-4 administrator shall approve or deny the claim within 30 days after
2-5 receiving the additional information. If the claim is approved, the
2-6 administrator shall pay the claim within 30 days after he receives the
2-7 additional information. If the approved claim is not paid within that
2-8 period, the administrator shall pay interest on the claim in the manner
2-9 prescribed in subsection 1.
2-10 3. An administrator shall not request a claimant to resubmit
2-11 information that the claimant has already provided to the administrator,
2-12 unless the administrator provides a legitimate reason for the request and
2-13 the purpose of the request is not to delay the payment of the claim, harass
2-14 the claimant or discourage the filing of claims.
2-15 4. An administrator shall not pay only part of a claim that has been
2-16 approved and is fully payable.
2-17 5. A court shall award costs and reasonable attorney’s fees to the
2-18 prevailing party in an action brought pursuant to this section.
2-19 6. The payment of interest provided for in this section for the late
2-20 payment of an approved claim may be waived only if the payment was
2-21 delayed because of an act of God or another cause beyond the control of
2-22 the administrator.
2-23 7. The commissioner may require an administrator to provide
2-24 evidence which demonstrates that the administrator has substantially
2-25 complied with the requirements set forth in this section, including,
2-26 without limitation, payment within 30 days of at least 95 percent of
2-27 approved claims or at least 90 percent of the total dollar amount for
2-28 approved claims. If the commissioner determines that an administrator
2-29 is not in substantial compliance with the requirements set forth in this
2-30 section, the commissioner may require the administrator to pay an
2-31 administrative fine in an amount to be determined by the commissioner.
2-32 Sec. 2. NRS 689A.035 is hereby amended to read as follows:
2-33 689A.035 An insurer [may] shall not charge a provider of health care
2-34 a fee to include the name of the provider on a list of providers of health
2-35 care given by the insurer to its insureds. [The amount of the fee must be
2-36 reasonable and must not exceed an amount that is directly related to the
2-37 administrative costs of the insurer to include the provider on the list.]
2-38 Sec. 3. NRS 689A.410 is hereby amended to read as follows:
2-39 689A.410 1. Except as otherwise provided in subsection 2, an insurer
2-40 shall approve or deny a claim relating to a policy of health insurance
2-41 within 30 days after the insurer receives the claim. If the claim is
2-42 approved, the insurer shall pay the claim within 30 days after it is
2-43 approved. [If] Except as otherwise provided in this section, if the
2-44 approved claim is not paid within that period, the insurer shall pay interest
2-45 on the claim at [the] a rate of interest [established pursuant to NRS 99.040
2-46 unless a different rate of interest is established pursuant to an express
2-47 written contract between the insurer and the provider of health care.] equal
2-48 to the prime rate at the largest bank in Nevada, as ascertained by the
2-49 commissioner of financial institutions, on January 1 or July 1, as the
2-50 case may be, immediately preceding the date on which the payment was
2-51 due, plus 6 percent. The
3-1 interest must be calculated from 30 days after the date on which the claim
3-2 is approved until the date on which the claim is paid.
3-3 2. If the insurer requires additional information to determine whether
3-4 to approve or deny the claim, it shall notify the claimant of its request for
3-5 the additional information within 20 days after it receives the claim. The
3-6 insurer shall notify the provider of health care of all the specific reasons
3-7 for the delay in approving or denying the claim. The insurer shall approve
3-8 or deny the claim within 30 days after receiving the additional
3-9 information. If the claim is approved, the insurer shall pay the claim
3-10 within 30 days after it receives the additional information. If the approved
3-11 claim is not paid within that period, the insurer shall pay interest on the
3-12 claim in the manner prescribed in subsection 1.
3-13 3. An insurer shall not request a claimant to resubmit information that
3-14 the claimant has already provided to the insurer, unless the insurer
3-15 provides a legitimate reason for the request and the purpose of the request
3-16 is not to delay the payment of the claim, harass the claimant or discourage
3-17 the filing of claims.
3-18 4. An insurer shall not pay only part of a claim that has been approved
3-19 and is fully payable.
3-20 5. A court shall award costs and reasonable attorney’s fees to the
3-21 prevailing party in an action brought pursuant to this section.
3-22 6. The payment of interest provided for in this section for the late
3-23 payment of an approved claim may be waived only if the payment was
3-24 delayed because of an act of God or another cause beyond the control of
3-25 the insurer.
3-26 7. The commissioner may require an insurer to provide evidence
3-27 which demonstrates that the insurer has substantially complied with the
3-28 requirements set forth in this section, including, without limitation,
3-29 payment within 30 days of at least 95 percent of approved claims or at
3-30 least 90 percent of the total dollar amount for approved claims. If the
3-31 commissioner determines that an insurer is not in substantial
3-32 compliance with the requirements set forth in this section, the
3-33 commissioner may require the insurer to pay an administrative fine in
3-34 an amount to be determined by the commissioner.
3-35 Sec. 4. NRS 689B.015 is hereby amended to read as follows:
3-36 689B.015 An insurer that issues a policy of group health insurance
3-37 [may] shall not charge a provider of health care a fee to include the name
3-38 of the provider on a list of providers of health care given by the insurer to
3-39 its insureds. [The amount of the fee must be reasonable and must not
3-40 exceed an amount that is directly related to the administrative costs of the
3-41 insurer to include the provider on the list.]
3-42 Sec. 5. NRS 689B.255 is hereby amended to read as follows:
3-43 689B.255 1. Except as otherwise provided in subsection 2, an insurer
3-44 shall approve or deny a claim relating to a policy of group health insurance
3-45 or blanket insurance within 30 days after the insurer receives the claim. If
3-46 the claim is approved, the insurer shall pay the claim within 30 days after
3-47 it is approved. [If] Except as otherwise provided in this section, if the
3-48 approved claim is not paid within that period, the insurer shall pay interest
3-49 on the claim at [the] a rate of interest [established pursuant to NRS 99.040
3-50 unless a different rate of interest is established pursuant to an express
4-1 written contract between the insurer and the provider of health care.] equal
4-2 to the prime rate at the largest bank in Nevada, as ascertained by the
4-3 commissioner of financial institutions, on January 1 or July 1, as the
4-4 case may be, immediately preceding the date on which the payment was
4-5 due, plus 6 percent. The interest must be calculated from 30 days after the
4-6 date on which the claim is approved until the date on which the claim is
4-7 paid.
4-8 2. If the insurer requires additional information to determine whether
4-9 to approve or deny the claim, it shall notify the claimant of its request for
4-10 the additional information within 20 days after it receives the claim. The
4-11 insurer shall notify the provider of health care of all the specific reasons
4-12 for the delay in approving or denying the claim. The insurer shall approve
4-13 or deny the claim within 30 days after receiving the additional
4-14 information. If the claim is approved, the insurer shall pay the claim
4-15 within 30 days after it receives the additional information. If the approved
4-16 claim is not paid within that period, the insurer shall pay interest on the
4-17 claim in the manner prescribed in subsection 1.
4-18 3. An insurer shall not request a claimant to resubmit information that
4-19 the claimant has already provided to the insurer, unless the insurer
4-20 provides a legitimate reason for the request and the purpose of the request
4-21 [in] is not to delay the payment of the claim, harass the claimant or
4-22 discourage the filing of claims.
4-23 4. An insurer shall not pay only part of a claim that has been approved
4-24 and is fully payable.
4-25 5. A court shall award costs and reasonable attorney’s fees to the
4-26 prevailing party in an action brought pursuant to this section.
4-27 6. The payment of interest provided for in this section for the late
4-28 payment of an approved claim may be waived only if the payment was
4-29 delayed because of an act of God or another cause beyond the control of
4-30 the insurer.
4-31 7. The commissioner may require an insurer to provide evidence
4-32 which demonstrates that the insurer has substantially complied with the
4-33 requirements set forth in this section, including, without limitation,
4-34 payment within 30 days of at least 95 percent of approved claims or at
4-35 least 90 percent of the total dollar amount for approved claims. If the
4-36 commissioner determines that an insurer is not in substantial
4-37 compliance with the requirements set forth in this section, the
4-38 commissioner may require the insurer to pay an administrative fine in
4-39 an amount to be determined by the commissioner.
4-40 Sec. 6. NRS 689C.435 is hereby amended to read as follows:
4-41 689C.435 A carrier serving small employers and a carrier that offers a
4-42 contract to a voluntary purchasing group [may] shall not charge a provider
4-43 of health care a fee to include the name of the provider on a list of
4-44 providers of health care given by the carrier to its insureds. [The amount
4-45 of the fee must be reasonable and must not exceed an amount that is
4-46 directly related to the administrative costs of the carrier to include the
4-47 provider on the list.]
4-48 Sec. 7. NRS 689C.485 is hereby amended to read as follows:
4-49 689C.485 1. Except as otherwise provided in subsection 2, a carrier
4-50 serving small employers and a carrier that offers a contract to a voluntary
5-1 purchasing group shall approve or deny a claim relating to a policy of
5-2 health insurance within 30 days after the carrier receives the claim. If the
5-3 claim is approved, the carrier shall pay the claim within 30 days after it is
5-4 approved. [If] Except as otherwise provided in this section, if the
5-5 approved claim is not paid within that period, the carrier shall pay interest
5-6 on the claim at [the] a rate of interest [established pursuant to NRS 99.040
5-7 unless a different rate of interest is established pursuant to an express
5-8 written contract between the carrier and the provider of health care.] equal
5-9 to the prime rate at the largest bank in Nevada, as ascertained by the
5-10 commissioner of financial institutions, on January 1 or July 1, as the
5-11 case may be, immediately preceding the date on which the payment was
5-12 due, plus 6 percent. The interest must be calculated from 30 days after the
5-13 date on which the claim is approved until the date on which the claim is
5-14 paid.
5-15 2. If the carrier requires additional information to determine whether to
5-16 approve or deny the claim, it shall notify the claimant of its request for the
5-17 additional information within 20 days after it receives the claim. The
5-18 carrier shall notify the provider of health care of all the specific reasons for
5-19 the delay in approving or denying the claim. The carrier shall approve or
5-20 deny the claim within 30 days after receiving the additional information. If
5-21 the claim is approved, the carrier shall pay the claim within 30 days after it
5-22 receives the additional information. If the approved claim is not paid
5-23 within that period, the carrier shall pay interest on the claim in the manner
5-24 prescribed in subsection 1.
5-25 3. A carrier shall not request a claimant to resubmit information that
5-26 the claimant has already provided to the carrier, unless the carrier provides
5-27 a legitimate reason for the request and the purpose of the request is not to
5-28 delay the payment of the claim, harass the claimant or discourage the
5-29 filing of claims.
5-30 4. A carrier shall not pay only part of a claim that has been approved
5-31 and is fully payable.
5-32 5. A court shall award costs and reasonable attorney’s fees to the
5-33 prevailing party in an action brought pursuant to this section.
5-34 6. The payment of interest provided for in this section for the late
5-35 payment of an approved claim may be waived only if the payment was
5-36 delayed because of an act of God or another cause beyond the control of
5-37 the carrier.
5-38 7. The commissioner may require a carrier to provide evidence
5-39 which demonstrates that the carrier has substantially complied with the
5-40 requirements set forth in this section, including, without limitation,
5-41 payment within 30 days of at least 95 percent of approved claims or at
5-42 least 90 percent of the total dollar amount for approved claims. If the
5-43 commissioner determines that a carrier is not in substantial compliance
5-44 with the requirements set forth in this section, the commissioner may
5-45 require the carrier to pay an administrative fine in an amount to be
5-46 determined by the commissioner.
5-47 Sec. 8. NRS 695A.095 is hereby amended to read as follows:
5-48 695A.095 A society [may] shall not charge a provider of health care a
5-49 fee to include the name of the provider on a list of providers of health care
5-50 given by the society to its insureds. [The amount of the fee must be
6-1 reasonable and must not exceed an amount that is directly related to the
6-2 administrative costs of the society to include the provider on the list.]
6-3 Sec. 9. NRS 695B.035 is hereby amended to read as follows:
6-4 695B.035 A corporation subject to the provisions of this chapter [may]
6-5 shall not charge a provider of health care a fee to include the name of the
6-6 provider on a list of providers of health care given by the corporation to its
6-7 insureds. [The amount of the fee must be reasonable and must not exceed
6-8 an amount that is directly related to the administrative costs of the
6-9 corporation to include the provider on the list.]
6-10 Sec. 10. NRS 695B.2505 is hereby amended to read as follows:
6-11 695B.2505 1. Except as otherwise provided in subsection 2, a
6-12 corporation subject to the provisions of this chapter shall approve or deny
6-13 a claim relating to a contract for dental, hospital or medical services within
6-14 30 days after the corporation receives the claim. If the claim is approved,
6-15 the corporation shall pay the claim within 30 days after it is approved. [If]
6-16 Except as otherwise provided in this section, if the approved claim is not
6-17 paid within that period, the corporation shall pay interest on the claim at
6-18 [the] a rate of interest [established pursuant to NRS 99.040 unless a
6-19 different rate of interest is established pursuant to an express written
6-20 contract between the corporation and the provider of health care.] equal to
6-21 the prime rate at the largest bank in Nevada, as ascertained by the
6-22 commissioner of financial institutions, on January 1 or July 1, as the
6-23 case may be, immediately preceding the date on which the payment was
6-24 due, plus 6 percent. The interest must be calculated from 30 days after the
6-25 date on which the claim is approved until the date on which the claim is
6-26 paid.
6-27 2. If the corporation requires additional information to determine
6-28 whether to approve or deny the claim, it shall notify the claimant of its
6-29 request for the additional information within 20 days after it receives the
6-30 claim. The corporation shall notify the provider of dental, hospital or
6-31 medical services of all the specific reasons for the delay in approving or
6-32 denying the claim. The corporation shall approve or deny the claim within
6-33 30 days after receiving the additional information. If the claim is
6-34 approved, the corporation shall pay the claim within 30 days after it
6-35 receives the additional information. If the approved claim is not paid
6-36 within that period, the corporation shall pay interest on the claim in the
6-37 manner prescribed in subsection 1.
6-38 3. A corporation shall not request a claimant to resubmit information
6-39 that the claimant has already provided to the corporation, unless the
6-40 corporation provides a legitimate reason for the request and the purpose of
6-41 the request is not to delay the payment of the claim, harass the claimant or
6-42 discourage the filing of claims.
6-43 4. A corporation shall not pay only part of a claim that has been
6-44 approved and is fully payable.
6-45 5. A court shall award costs and reasonable attorney’s fees to the
6-46 prevailing party in an action brought pursuant to this section.
6-47 6. The payment of interest provided for in this section for the late
6-48 payment of an approved claim may be waived only if the payment was
6-49 delayed because of an act of God or another cause beyond the control of
6-50 the corporation.
7-1 7. The commissioner may require a corporation to provide evidence
7-2 which demonstrates that the corporation has substantially complied with
7-3 the requirements set forth in this section, including, without limitation,
7-4 payment within 30 days of at least 95 percent of approved claims or at
7-5 least 90 percent of the total dollar amount for approved claims. If the
7-6 commissioner determines that a corporation is not in substantial
7-7 compliance with the requirements set forth in this section, the
7-8 commissioner may require the corporation to pay an administrative fine
7-9 in an amount to be determined by the commissioner.
7-10 Sec. 11. Chapter 695C of NRS is hereby amended by adding thereto
7-11 the provisions set forth as sections 11.3 and 11.7 of this act.
7-12 Sec. 11.3. 1. A health maintenance organization shall not:
7-13 (a) Enter into any contract or agreement, or make any other
7-14 arrangements, with a provider for the provision of health care; or
7-15 (b) Employ a provider pursuant to a contract, an agreement or any
7-16 other arrangement to provide health care,
7-17 unless the contract, agreement or other arrangement specifically
7-18 provides that the health maintenance organization and provider agree to
7-19 the schedule for the payment of claims set forth in NRS 695C.185.
7-20 2. Any contract, agreement or other arrangement between a health
7-21 maintenance organization and a provider that is entered into or renewed
7-22 on or after October 1, 2001, that does not specifically include a provision
7-23 concerning the schedule for the payment of claims as required by
7-24 subsection 1 shall be deemed to conform with the requirements of
7-25 subsection 1 by operation of law.
7-26 Sec. 11.7. Any contract or other agreement entered into or renewed
7-27 by a health maintenance organization on or after October 1, 2001:
7-28 1. To provide health care services through managed care to
7-29 recipients of Medicaid under the state plan for Medicaid; or
7-30 2. With the division of health care financing and policy of the
7-31 department of human resources to provide insurance pursuant to the
7-32 children’s health insurance program,
7-33 must require the health maintenance organization to pay interest to a
7-34 provider of health care services on a claim that is not paid within the
7-35 time provided in the contract or agreement at a rate of interest equal to
7-36 the prime rate at the largest bank in Nevada, as ascertained by the
7-37 commissioner of financial institutions, on January 1 or July 1, as the
7-38 case may be, immediately preceding the date on which the payment was
7-39 due, plus 6 percent. The interest must be calculated from 30 days after
7-40 the date on which the claim is approved until the date on which the
7-41 claim is paid.
7-42 Sec. 12. NRS 695C.050 is hereby amended to read as follows:
7-43 695C.050 1. Except as otherwise provided in this chapter or in
7-44 specific provisions of this Title, the provisions of this Title are not
7-45 applicable to any health maintenance organization granted a certificate of
7-46 authority under this chapter. This provision does not apply to an insurer
7-47 licensed and regulated pursuant to this Title except with respect to its
7-48 activities as a health maintenance organization authorized and regulated
7-49 pursuant to this chapter.
8-1 2. Solicitation of enrollees by a health maintenance organization
8-2 granted a certificate of authority, or its representatives, must not be
8-3 construed to violate any provision of law relating to solicitation or
8-4 advertising by practitioners of a healing art.
8-5 3. Any health maintenance organization authorized under this chapter
8-6 shall not be deemed to be practicing medicine and is exempt from the
8-7 provisions of chapter 630 of NRS.
8-8 4. The provisions of NRS 695C.110, 695C.170 to 695C.200, inclusive,
8-9 [and] sections 19 and 20 of [this act,] Senate Bill No. 2 of this session,
8-10 section 11.3 of this act and NRS695C.250 and 695C.265 do not apply to
8-11 a health maintenance organization that provides health care services
8-12 through managed care to recipients of Medicaid under the state plan for
8-13 Medicaid or insurance pursuant to the children’s health insurance program
8-14 pursuant to a contract with the division of health care financing and policy
8-15 of the department of human resources. This subsection does not exempt a
8-16 health maintenance organization from any provision of this chapter for
8-17 services provided pursuant to any other contract.
8-18 5. The provisions of NRS 695C.1694 and 695C.1695 apply to a health
8-19 maintenance organization that provides health care services through
8-20 managed care to recipients of Medicaid under the state plan for Medicaid.
8-21 Sec. 13. NRS 695C.055 is hereby amended to read as follows:
8-22 695C.055 1. The provisions of NRS 449.465, 679B.158, subsections
8-23 2, 4, 18, 19 and 32 of NRS 680B.010, NRS 680B.025 to 680B.060,
8-24 inclusive, [and 695G.010 to 695G.260, inclusive,] chapter 695G of NRS
8-25 and section 16 of this act, apply to a health maintenance organization.
8-26 2. For the purposes of subsection 1, unless the context requires that a
8-27 provision apply only to insurers, any reference in those sections to
8-28 “insurer” must be replaced by “health maintenance organization.”
8-29 Sec. 14. NRS 695C.125 is hereby amended to read as follows:
8-30 695C.125 A health maintenance organization [may] shall not charge a
8-31 provider of health care a fee to include the name of the provider on a list
8-32 of providers of health care given by the health maintenance organization to
8-33 its enrollees. [The amount of the fee must be reasonable and must not
8-34 exceed an amount that is directly related to the administrative costs of the
8-35 health maintenance organization to include the provider on the list.]
8-36 Sec. 15. NRS 695C.185 is hereby amended to read as follows:
8-37 695C.185 1. Except as otherwise provided in subsection 2, a health