Nevada Rev. Statutes-Title 57-Chapter 683A. Persons Involved in Sale or Administration of Insurance-Administrators
Approval or denial of claims; payment of claims and interest; requests for additional information; award of costs and attorney’s fees; compliance with requirements; imposition of administrative fine or suspension or revocation of certificate of registration for failure to comply
1. Except as otherwise provided in subsection 3 and NRS 439B.754, an administrator shall approve or deny a claim relating to health insurance coverage and, if the administrator:
(a) Approves the claim, pay the claim within:
(1) Twenty-one days after the administrator receives the claim, if the claim is submitted electronically; or
(2) Thirty days after the administrator receives the claim, if the claim is not submitted electronically.
(b) Denies the claim, notify the claimant in writing of the denial within 21 days after the administrator receives the claim, if the claim is submitted electronically, or 30 days after the administrator receives the claim, if the claim is not submitted electronically. The notice must include, without limitation:
(1) All reasons for denying the claim, including, without limitation, the specific facts and provisions of the policy relied upon by the administrator as a basis to deny the claim;
(2) The criteria by which the administrator determines whether to approve or deny the claim and a description of the manner in which the administrator applied those criteria to the claim; and
(3) A summary of any applicable process established pursuant to NRS 687B.820 for challenging the denial of the claim.
2. Except as otherwise provided in this section, if the approved claim is not paid within the period specified in subsection 1, the administrator shall pay interest on the claim at a rate of 10 percent per annum. The interest must be calculated from the date on which payment of the claim is due pursuant to subsection 1 until the date on which the claim is paid.
3. If the administrator requires additional information to determine whether to approve or deny the claim, the administrator shall notify the claimant of the administrator’s request for the additional information within 20 working days after receiving the claim. The administrator shall notify the claimant of all the specific reasons for the delay in approving or denying the claim. The administrator shall approve or deny the claim and, if the administrator:
(a) Approves the claim, pay the claim within:
(1) Twenty-one days after receiving the additional information, if the information is submitted electronically; or
(2) Thirty days after receiving the additional information, if the information is not submitted electronically.
(b) Denies the claim, provide notice of the denial in the manner prescribed in paragraph (b) of subsection 1 within 21 days after receiving the additional information, if the information is submitted electronically, or 30 days after receiving the additional information, if the information is not submitted electronically.
4. If a claim approved pursuant to subsection 3 is not paid within the period specified in that subsection, the administrator shall pay interest on the claim in the manner prescribed in subsection 2.
5. An administrator shall not:
(a) Deny a claim relating to health insurance coverage without a reasonable basis for the denial.
(b) Request a claimant to resubmit information that the claimant has already provided to the administrator, unless the administrator provides a legitimate reason for the request and the purpose of the request is not to delay the payment of the claim, harass the claimant or discourage the filing of claims.
6. An administrator shall not pay only part of a claim that has been approved and is fully payable.
7. A court shall award costs and reasonable attorney’s fees to the prevailing party in an action brought pursuant to this section.
8. The payment of interest provided for in this section for the late payment of an approved claim may be waived only if the payment was delayed because of an act of God or another cause beyond the control of the administrator.
9. The Commissioner may require an administrator to provide evidence which demonstrates that the administrator has substantially complied with the requirements set forth in this section, including, without limitation, payment within the time periods specified by this section of at least 95 percent of approved claims or at least 90 percent of the total dollar amount for approved claims.
10. If the Commissioner determines that an administrator is not in substantial compliance with the requirements set forth in this section or has failed to approve or deny a claim or pay an approved claim within 60 working days after receiving the claim, the Commissioner may require the administrator to pay an administrative fine in an amount to be determined by the Commissioner or has failed to approve or deny a claim or pay an approved claim within 60 working days after receiving the claim, Upon a second or subsequent determination that an administrator is not in substantial compliance with the requirements set forth in this section or has failed to approve or deny a claim or pay an approved claim within 60 working days after receiving the claim, the Commissioner may suspend or revoke the certificate of registration of the administrator.
11. On or before February 1 of each year, an administrator that was responsible for the approval and denial of claims relating to health insurance coverage in this State during the immediately preceding calendar year shall submit to the Commissioner a report concerning the compliance of the administrator with the requirements of this section during that calendar year. The report must include, without limitation:
(a) The number of claims for which the administrator failed to comply with the requirements of subsections 1 and 3 during the immediately preceding calendar year; and (b) The total amount of interest paid by the administrator pursuant to subsections 2 and 4 during the immediately preceding calendar year.
12. The provisions of this section do not apply to a claim relating to health coverage under Medicaid, the Children’s Health Insurance Program or the Public Employees’ Benefits Program.