Nevada Administrative Code

NAC 695C.285 Limitation on frequency of increases in premium rates; exceptions. (NRS 679B.130, 695C.275) 1. Except as otherwise provided in this section, an organization shall not increase the premium rates for a group health care plan more frequently than every 6 months unless t…

NAC 695C.290 Filing, contents and delivery of disclosure summarizing coverage by health maintenance organization. (NRS 679B.130, 695C.193) 1. Each health maintenance organization shall file with the Commissioner, for his or her approval, a disclosure summarizing the coverage prov…

NAC 695C.295 Disclosures in advertising and sales materials; inclusion of certain information in health care plan. (NRS 679B.130, 695C.193) 1. As part of the disclosure required by NRS 695C.193, an organization shall disclose in the advertising and sales materials that the organi…

NAC 695C.300 Requirements for conducting examination. (NRS 679B.130, 695C.275, 695C.310) Each examination of an organization, including one made pursuant to NRS 695C.310 or NAC 695C.325, must be conducted in accordance with the requirements found in the handbooks and manuals adop…

NAC 695C.310 Health maintenance organization: Review of examination of organization required; approved examiners; organization to cooperate during examination. (NRS 439.200, 679B.130, 695C.310) 1. As part of the examination of the quality of health care services for a health main…

NAC 695C.320 Health maintenance organization: Division of Public and Behavioral Health to notify organization of its findings; objections to findings; dispute resolution; distribution of proposed findings. (NRS 439.200, 679B.130, 695C.310) 1. Not less than 90 days after an examin…

NAC 695C.325 Provider-sponsored organization: Frequency of examinations; submission of records; acceptance of alternate report. (NRS 679B.130, 695C.275) 1. The Commissioner will make an examination of the affairs of any provider-sponsored organization and providers with whom such…

NAC 695C.330 Provider-sponsored organization: Determination of financial condition. (NRS 679B.130, 695C.275) 1. To determine its financial condition, fulfillment of its contractual obligations and compliance with law, the Commissioner will, as often as he or she deems advisable, …

NAC 695C.335 Provider-sponsored organization: Procedure; appointment of examiner; maintenance and use of records. (NRS 679B.130, 695C.275) 1. If the Commissioner examines a provider-sponsored organization pursuant to NAC 695C.330, he or she will designate one or more examiners an…

NAC 695C.340 Provider-sponsored organization: Payment of expenses. (NRS 679B.130, 695C.275) 1. The provider-sponsored organization being examined shall pay the expense of an examination. The expenses to be paid include only the reasonable and proper travel and lodging expenses of…

NAC 695C.345 Provider-sponsored organization: Statutory procedures required for examination and hearing. (NRS 679B.130, 695C.275) The Commissioner will use the procedures required by: 1. NRS 679B.230 to 679B.290, inclusive, when conducting an examination of a provider-sponsored o…

NAC 695C.350 Notice and approval required for modification of operations. (NRS 679B.130, 695C.275) A provider-sponsored organization shall, unless otherwise provided for in this chapter, file a notice with the Commissioner before any material modification of the operations descri…

NAC 695C.355 Accounting principles required for certain reports and transactions. (NRS 679B.130, 695C.275) A provider-sponsored organization shall use accounting principles that are recognized by the laws of this State or approved by the Commissioner for: 1. All financial reports…

NAC 695C.360 Annual report of financial condition and financial statement; administrative penalty for failure to file report or statement; request for extension. (NRS 679B.130, 695C.275) 1. A provider-sponsored organization shall file with the Commissioner on or before March 1 of…

NAC 695C.365 Fees. (NRS 679B.130, 695C.275) 1. A provider-sponsored organization subject to this chapter shall pay to the Commissioner the following fees: (a) For filing an application for a certificate of authority, $2,450. (b) For issuance of a certificate of authority, $250. (…

NAC 695C.370 Availability of information for inspection. (NRS 679B.130, 695C.275) A provider-sponsored organization shall have available for inspection the following information: 1. A current statement of financial condition including a balance sheet and summary of receipts and d…

NAC 695C.375 Prohibited practices. (NRS 679B.130, 695C.275) 1. No provider-sponsored organization or representative thereof may cause or knowingly permit the use of advertising or solicitation which is untrue or misleading. For purposes of this chapter: (a) A statement or item of…

NAC 695C.380 Rehabilitation, liquidation or conservation. (NRS 679B.130, 695C.275) Any rehabilitation, liquidation or conservation of a provider-sponsored organization shall be deemed to be the rehabilitation, liquidation or conservation of an insurance company and will be conduc…

NAC 695C.400 Requirements; written description of action plan; staff; periodic review of program. (NRS 439.200) 1. Each organization shall establish a quality assurance program which consists of a method for analyzing the outcomes of health care, peer review, the collection of he…

NAC 695C.410 Quality assurance committee: Appointment of members; staff; duties. (NRS 439.200) 1. The program established pursuant to NAC 695C.400 must include a quality assurance committee which is directed by either a licensed physician or dentist, as appropriate. The organizat…

NAC 695C.420 System for collection and maintenance of information related to health care services. (NRS 439.200) 1. The quality assurance program must include a system to collect and maintain information related to the health care services received by members. 2. The system must …

NAC 695C.430 Written guidelines for remedial action; final determinations regarding quality of care. (NRS 439.200) 1. The quality assurance program must include written guidelines which set forth the procedures for remedial action when problems related to quality of care are iden…

NAC 695C.500 Compliance with statutory provisions. (NRS 679B.130, 695C.275) An organization shall ensure that a delivery system intermediary complies with the applicable provisions of title 57 of NRS relating to any services performed on behalf of the organization. (Added to NAC …

NAC 695C.505 Required provisions of health service contracts. (NRS 679B.130, 695C.275) Each health service contract submitted to the Commissioner pursuant to NAC 695C.510 must contain a provision which: 1. Requires the delivery system intermediary to provide to the organization a…

NAC 695C.510 Health service contract to be filed with Commissioner; certain documentation to be included in contract. (NRS 679B.130, 695C.275) 1. An organization which enters into a health service contract with a delivery system intermediary shall file a copy of the health servic…

NAC 695C.515 Commissioner may order cancellation or renegotiation of health service contract under certain circumstances. (NRS 679B.130, 695C.275) The Commissioner may order the immediate cancellation or renegotiation of any health service contract if he or she determines that th…

NAC 695C.520 Conditions for paying claims or acting as agent for utilization review. (NRS 679B.130) If a delivery system intermediary intends to pay claims or act as an agent for utilization review, the delivery system intermediary must: 1. Obtain the appropriate licenses require…

NAC 695C.525 Provision of health care services. (NRS 679B.130) 1. A delivery system intermediary may employ or enter into a contract with a provider to furnish or arrange for the furnishing of health care services to the members of an organization covered under a health care plan…

NAC 695C.530 Contract for provision of health care services. (NRS 679B.130) A contract entered into by a delivery system intermediary and a provider for the provision of health care services must: 1. Describe the responsibilities of the provider and the delivery system intermedia…

NAC 695C.535 Organization prohibited from requiring provision of health care services for which delivery system intermediary has not contracted except under certain circumstances. (NRS 679B.130, 695C.275) 1. An organization shall not require a delivery system intermediary to prov…

NAC 695C.540 Contract for evaluation of credentials of providers. (NRS 679B.130, 695C.275) 1. An organization may enter into a contract with a delivery system intermediary for evaluating the credentials of those providers who will provide health care services to the members of th…

NAC 695C.545 Commissioner to have access to books and records. (NRS 679B.130, 695C.275) An organization shall take all reasonable measures to provide the Commissioner with access to the books and records of any delivery system intermediary with which it contracts for the provisio…

NAC 695C.550 Prohibited acts. (NRS 679B.130) A delivery system intermediary shall not: 1. Solicit or sell to a person or group any health care plan which provides for comprehensive health care services unless it complies with the requirements set forth in NAC 695C.150; or 2. Cont…

NAC 695D.010 Definitions. (NRS 679B.130, 695D.100) As used in this chapter, unless the context otherwise requires, the words and terms defined in NAC 695D.015 to 695D.060, inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Comm’r of Insurance, eff. …

NAC 695D.015 “Commissioner” defined. “Commissioner” means the Commissioner of Insurance. (Supplied in codification)

NAC 695D.020 “Division” defined. (NRS 679B.130, 695D.100) “Division” means the Division of Insurance of the Department of Business and Industry. (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92)

NAC 695D.025 “Member” defined. (NRS 679B.130, 695D.100) “Member” has the meaning ascribed to it in NRS 695D.050. (Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)

NAC 695D.030 “Organization” defined. (NRS 679B.130, 695D.100) “Organization” means an organization for dental care as defined by NRS 695D.060. (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

NAC 695D.040 “Plan” defined. (NRS 679B.130, 695D.100) “Plan” means a plan for dental care as defined by NRS 695D.070. (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

NAC 695D.045 “Policy” defined. (NRS 679B.130, 695D.100) “Policy” has the meaning ascribed to it in NRS 695D.080. (Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)

NAC 695D.050 “Provider” defined. (NRS 679B.130, 695D.100) “Provider” means a person who provides dental care. (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

NAC 695D.060 “Service” defined. (NRS 679B.130, 695D.100) “Service” means the provision of dental care. (Added to NAC by Comm’r of Insurance, eff. 12-2-88) APPLICATION FOR CERTIFICATE OF AUTHORITY

NAC 695D.070 Submission; format. (NRS 679B.130, 695D.100, 695D.120) 1. An organization that applies for a certificate of authority must submit to the Commissioner an original and two copies of its application. 2. The original and each copy of the application must be submitted in …

NAC 695D.080 Contents. (NRS 679B.130, 695D.100, 695D.120) 1. In addition to the information required to be submitted pursuant to NRS 695D.120, an applicant for a certificate of authority shall include in its application: (a) A list of its actual and prospective providers; (b) A c…

NAC 695D.090 Applicant licensed in another state. (NRS 679B.130, 695D.100, 695D.120) Any applicant licensed as an organization in another state, or having an affiliate or subsidiary that is so licensed, shall include in its application: 1. A copy of the license; and 2. If it is a…

NAC 695D.100 Incomplete application. (NRS 679B.130, 695D.100) 1. Any incomplete application, with respect to which there is no activity by the applicant for 60 days or more, shall be deemed to have been withdrawn by the applicant. 2. If an application is deemed withdrawn, the Div…

NAC 695D.110 Request to review or obtain copy; notification of pending application. (NRS 679B.130, 695D.100) 1. Any person who wishes to review or obtain a copy of an application for a certificate of authority must submit a written request to the offices of the Division at 1818 E…