AB 52 — Revises provisions relating to the payment of claims under policies of health insurance. (BDR 57-367)

- *AB52_R1* – 4 – 3.

(a)- A83rd campaignSession to(2025) inform– providers4 of– health care and insureds of the provisions of NRS 683A.0879, 687B.730,687B.730,nd 687B.820, 689A.410, 689A.755, 689B.0295, 689B.255, 689C.335, 695A.188, 695B.2505, 695B.400, 695D.215 and 695G.230 and sections 15 and 16 of this act;

Sec.683A.0879 1.S 683Except as otherwise provided in subsection [2] and NRS 439B.754, an administrator shall approve or deny a claim relating to health insurance coverage and, if the administrator:

2.

NRS 683A.0879 is hereby amended to read as follows:

683A.0879 1.

Except as otherwise provided in subsection [2] 3 and NRS 439B.754, an administrator shall approve or deny a claim relating to health insurance coverage and, if the administrator:

(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.electr(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 noticecriteria mustby include,which withoutthe limitation: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;

(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;

- *AB52_R1* – 5 – (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;

- 83rd Session (2025) – 5 – 2.

Except as otherwise provided in this section, if the approved claim is not paid within [that] the period [,] specified in subsection 1, the administrator shall pay interest on the claim at a rate of [interest equal to the prime rate at the largest bank in Nevada, as ascertained by the Commissioner of Financial Institutions, on January 1 or July 1, as the case may be, immediately preceding the date on which the payment was due, plus 6] 10 percent [.] per annum.

If the claim is approved, the administrator shall pay the claim within 30 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.

(b) Request a claimant to resubmit information that the claimant has already provided to the administrator, unless the administrator - *AB52_R1* – 6 – 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.

[4.]- 6.83rd Session (2025) – 6 – has been approved and is fully payable.pay only part of a claim that [5.] 7.

An administrator shall not pay only part of a claim that has been approved and is fully payable.

[5.] 7.

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, an the Commissioner may require the administrator to pay an administrative fine in an amount to be determined by the Commissioner.

The report mustmus(a) include,The withoutnumber limitation:of claims for which the administrator failed to comply with the requirements of subsections 1 and 3 during the immediately preceding calendar year;

(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;

-12. *AB52_R1* – 7 – Sec.

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.

- 83rd Session (2025) – 7 – Sec.

687B.730 A1. health carrier which offers or issues a network plan shall [notify] :

1.A health carrier which offers or issues a network plan shall [notify] :

(a) Notify each participating provider of health care in the network of the responsibilities of the participating provider of health care with respect to any applicable administrative policies andandf health programs of the health carrier including, without limitation, any applicable administrative policies and programs concerning:

[1.] (a)(1) Terms of payment;

[2.] (b)(2) Utilization review;

[3.] (c)(3) Quality assessment and improvement;

[4.] (d)(4) Credentialing;

[5.] (e)(5) Procedures for grievances and appeals;

[6.] (f)(6) Requirements for data reporting;

[7.] (g)(7) Requirements for timely notice to the health carrier of changes in the practices of the participating provider of health care, such as discontinuance of accepting new patients;

[8.] (h)(8) Requirements for confidentiality;

and [9.] (i)(9) Any applicable federal or state programs.

2.(b) Provide to each participating provider of health care in the network and each covered person at least annually a detailed explanation of the process by which the health carrier will pay claims submitted by participating providers of health care, including, without limitation, the contact information for the department of the health carrier that is responsible for reviewing claims that have been denied in accordance with the process established pursuant to NRS 687B.820.

Provide to each participating provider of health care inservices theby networka andmanaged eachcare coveredorganization personto:rovision at(a) leastRecipients annually a detailed explanation of theMedicaid processunder by which the healthState carrierPlan willfor payMedicaid claimsor submittedinsurance bypursuant participatingto providersthe ofChildren’s healthHealth care,Insurance including,Program withoutpursuant limitation,to thea contactcontract informationwith for the departmentDivision of theHealth healthCare carrierFinancing thatand isPolicy responsibleof for reviewing claims that have been denied in accordance with the processDepartment establishedof pursuantHealth toand NRSHuman 687B.820.Services;

or (b) Members of the Public Employees’ Benefits Program.

3.

As used in this section, “managed care organization” has the meaning ascribed to it in NRS 695G.050.

687B.820 A1. health carrier which offers or issues a network plan shall establish procedures for the resolution of administrative, payment or other disputes between a participating provider of health care in the network and the health carrier.

ThoseA health carrier which offers or issues a network plan shall establish procedures mustfor include,the withoutresolution limitation,of anadministrative, efficientpayment processor byother whichdisputes between a participating provider of health care mayin challenge the denialnetwork ofand a claim by the health carrier.

TheThose processprocedures must allowinclude, forwithout thelimitation, clearan resolutionefficient ofprocess eachby challengewhich within a reasonable- time.83rd Session (2025) – 8 – claim by the health carrier.

The process must allow for the clear a resolution of each challenge within a reasonable time.

2.

The provisions of this section do not apply to the provision of health care services by a managed care organization to:

(a) Recipients of Medicaid under the State Plan for Medicaid or insurance pursuant to the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Health and Human Services;

or (b) Members of the Public Employees’ Benefits Program.

3.

As used in this section, “managed care organization” has the meaning ascribed to it in NRS 695G.050.

Except as otherwise provided in subsection 2 and NRS 439B.754, an insurer shall approve or deny a claim relating to a policy of health insurance within 21 days after the insurer receives the claim, if the claim is submitted electronically, or 30 days after the insurer receives the claim [.] , if the claim is not submitted electronically.

Except as otherwise provided in this section, if the approved claim - *AB52_R1* – 8 – is not paid within that period, the insurer shall pay interest on the claim at a rate of [interest equal to the prime rate at the largest bank in Nevada, as ascertained by the Commissioner of Financial Institutions, on January 1 or July 1, as the case may be, immediately preceding the date on which the payment was due, plus 6] 10 percent [.] per annum.

If the insurer requires additional information to determine whether to approve or deny the claim, it shall notify the claimant of its request for the additional information within 20 working days after it receives the claim.

If the approved - 83rd Session (2025) – 9 – claim is not paid within that period, the insurer shall pay interest on the claim in the manner prescribed in subsection 1.

(b) Request a claimant to resubmit information that the claimant has already provided to the insurer, unless the insurer provides aat 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.

- *AB52_R1* – 9 – 8.

If the Commissioner determines that an insurer is not in substantial compliance with the requirements set forth in this section [,] or that the insurer 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 insurer to pay an administrative fine in an amount to be determined by thethen Commissioner.

and (b)- The83rd totalSession amount(2025) of– interest10 paid– by the insurer pursuant to subsections 1 and 2 during the immediately preceding calendarcalendarant to year.

Any time that an insurer denies coverage of a health care service to an insured, including, without limitation, denying a claim relating to a policy of health insurance pursuant to NRS 689A.410, it shall notify the insured and, if applicable, the provider of health care who submitted the claim, in writing within :

- *AB52_R1* – 10 – (b) Thirty days after the insurer receives all information necessary to make a determination concerning the claim, if the information was not submitted electronically;

(a) [The reason] All reasons for denying coverage of the service [;] , including, without limitation, the specific facts and provisions of the policy relied upon by the insurer as a basis to deny coverage of (b) The criteria by which the insurer determines whether to authorize or deny coverage of the health care service [;] and a description of the manner in which the insurer applied those criteria to the health care service;

(b) The criteria by which the insurer determines whether to authorize or deny coverage of the health care service [;] and a description of the manner in which the insurer applied those criteria to the health care service;

- 83rd Session (2025) – 11 – [3.] 4.

Sec.689B.0295 1.S 689BFollowing approval by the Commissioner, each insurer that issues a policy of group health insurance in this State shall provide written notice to an insured, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the insured to file a written complaint.

7.

NRS 689B.0295 is hereby amended to read as follows:

689B.0295 1.

Following approval by the Commissioner, each insurer that issues a policy of group health insurance in this State shall provide written notice to an insured, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the insured to file a written complaint.

- *AB52_R1* – 11 – (b) Thirty days after the insurer receives all information necessary to make a determination concerning the claim, if the information is not submitted electronically;

or (c) If no claim is received, within 10 working days after [it] the insurer denies coverage of the health care service .

[of:][of:]er [it] the 3.

- 83rd Session (2025) – 12 – [3.] 4.

If an insurer denies a claim submitted by a provider of healthwriting care,of the insurerdenial shallwithin:l notify the provider of health care in writing(a) ofTwenty-one days after the denialinsurer within:receives all information necessary to make a determination concerning the claim, if the information is submitted electronically;

(a) Twenty-one days after the insurer receives all information necessary to make a determination concerning the claim, if the information is submitted electronically;

Except as otherwise provided in subsection 2 and NRS 439B.754, an insurer shall approve or deny a claim relating to a policy of group health insurance or blanket insurance within 21 days after the insurer receives the claim, if the claim is - *AB52_R1* – 12 – submitted electronically, or 30 days after the insurer receives the claimapproved, [.]the ,insurer ifshall also pay the claim within [30 days after itis is notapproved.] submittedthat electronically.period.

If the claim is approved, the insurer shall also pay the claim within [30 days after it is approved.] that period.

The insurer shall notify the [provider of health- care]83rd claimantSession of(2025) all– the13 specific– reasons for the delay in approving or denying the claim.

The insurer shall approve or denydenyn the claim within 21 days after receiving the additional information, if the additional information is submitted electronically, or 30 days after receiving the additional information [.] , if the additional information is not submitted electronically.

4.approved and is fully payable.ay only part of a claim that has been 5.

An insurer shall not pay only part of a claim that has been approved and is fully payable.

5.

The Commissioner may require an insurer to provide evidence which demonstrates that the insurer has substantially complied with the requirements set forth in this section, including, - *AB52_R1* – 13 – without limitation, payment within [30 days] 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.

If the Commissioner determines that an insurer 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, thetheoved Commissioner may require the insurer to pay an administrative fine in an amount to be determined by the Commissioner.

Upon a second or subsequent determination that an insurer 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 authority of the insurer.

- 83rd Session (2025) – 14 – 9.

The report must include, withoutwit(a) limitation:The number of claims for which the insurer failed to comply with the requirements of subsections 1 and 2 during the immediately preceding calendar year;

(a) The number of claims for which the insurer failed to comply with the requirements of subsections 1 and 2 during the immediately preceding calendar year;

The notice must(1) include,All reasons for denying the claim, including, without limitation:limitation, the specific facts and provisions of the policy relied upon by the carrier as a basis to deny the claim;

(1)(2) AllThe reasonscriteria forby denyingwhich the claim,carrier including,determines withoutwhether limitation,to theapprove specificor factsdeny the claim and provisionsa description of the policymanner reliedin uponwhich by the carrier asapplied athose basiscriteria to deny the claim;

- *AB52_R1* – 14 – (2) The criteria by which the carrier determines whether to approve or deny the claim and a description of the manner in which the carrier applied those criteria to the claim;

The interest - 83rd Session (2025) – 15 – must be calculated from [30 days after] the date on which payment of the claim is [approved] due pursuant to subsection 1 until the date on which the claim is paid.

If the carrier requires additional information to determine whether to approve or deny the claim, it shall notify the claimant of its request for the additional information within 2020the working days after it receives the claim.

(a) Deny a claim without a reasonable basis for the denial.

- *AB52_R1* – 15 – [4.] 6.

The Commissioner may require a carrier to provide evidence which demonstrates that the carrier has substantially complied- with83rd theSession requirements(2025) set– forth16 in– this section, including, without limitation, payment within [30 days] the time periodsperiodsluding, 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.

Upon a second or subsequent determination that a carrier 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 authority of the carrier.

On or before February 1 of each year, a carrier shall submit to the Commissioner a report concerning the compliance of the carrier with the requirements of this section during the immediately preceding calendar year.

The report must include,include,he without limitation:

If the claim is approved, the society shall pay the claim within 30 days after iti(2) isThirty approved.days after the society receives the claim, if they;

If]or , if the claim is not submitted electronically;electronically.

or - *AB52_R1* – 16 – (2) Thirty days after the society receives the claim, if the claim is not submitted electronically.

- 83rd Session (2025) – 17 – (1) All reasons for denying the claim, including, without limitation, the specific facts and provisions of the certificate relied upon by the society as a basis to deny the claim;

(2) The criteria by which the society determines whether to approve or deny the claim and a description of the manner in which the society applied those criteria to the claim;

andandin (3) A summary of any applicable process established pursuant to NRS 687B.820 for challenging the denial of the claim.

or (2)the Thirtyclaim daysis approved, the society shall pay the claim within 30 daysIf after receivingit receives the additional information.] , if the information [.is not submitted electronically.

If the claim is approved, the society shall pay the claim within 30 days after it receives the additional information.] , if the information is not submitted electronically.

If [the approved] a claim approved pursuant to subsection 3 is not paid within [that] the period [,] specified in that subsection, - *AB52_R1* – 17 – the society shall pay interest on the claim in the manner prescribed in subsection [1.] 2.

(b)- Request83rd aSession claimant(2025) to– resubmit18 information– that the claimant has already provided to the society, unless the society provides aat 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.

The Commissioner may require a society to provide evidence which demonstrates that the society has substantially complied with the requirements set forth in this section, including, without limitation, payment within the time periods specified by thispercent section of atthe leasttotal 95dollar percentamount offor approved claimsclaims.or or at least 90 percent10. of the total dollar amount for approved claims.

10.

On or before February 1 of each year, a society shall submit to the Commissioner a report concerning the compliance of the society with the requirements of this section during the immediately preceding calendar year.

The report must include,include,he without limitation:

and - *AB52_R1* – 18 – (b) The total amount of interest paid by the society pursuant to subsections 2 and 4 during the immediately preceding calendar year.

Sec.- 83rd Session (2025) – 19 – follows:11.

11.NRS 695B.2505 is hereby amended to read as 695B.2505 1.

NRS 695B.2505 is hereby amended to read as follows:

695B.2505 1.

Except as otherwise provided in this section, if the approved claim is not paid within [that] that period, the corporation shall pay interest on the claim at a rate of [interest equal to the prime rate at the largest bank in Nevada, as ascertained by the Commissioner of Financial Institutions, on January 1 or July 1, as the case may be, immediately preceding the date on which the payment was due, plus 6] 10 percent [.] per annum.date on which the payment of the claim is [approved] due pursuant to this subsection until the date on which the claim is paid.

The interest must be calculated from [30 days after] the date on which the payment of the claim is [approved] due pursuant to this subsection until the date on which the claim is paid.

If the approved claim is not paid within that period, the corporationin shallsubsection 1.l pay interest on the claim in the manner prescribed in3. subsection 1.

3.

- *AB52_R1*83rd Session (2025) – 1920 – 4.

6.late payment of an approved claim may be waived only if thefor the payment was delayed because of an act of God or another cause beyond the control of the corporation.

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 corporation.

On or before February 1 of each year, a corporation shall submit to the Commissioner a report concerning the compliance of the corporation with the requirements of this section during the immediately preceding calendar year.

Following approval by the Commissioner, each insurer that issues a contract for hospital or medical services in this State shall provide written notice to an insured, in clear and comprehensible language that is understandable to an ordinary - 83rd Session (2025) – 21 – layperson, explaining the right of the insured to file a written complaint.

- *AB52_R1* – 20 – (a) At the time the insured receives a certificate of coverage or evidence of coverage;

(b) Any time that the insurer denies coverage of a health care service or limits coverage of a health care service to an insured;

[(b)] (2) The criteria by which the insurer determines whether to authorize or deny coverage of the health care service [;] and the mannercare inservice;ch which the insurer applied those criteria to the health care(3) service;A summary of any applicable process established pursuant to NRS 687B.820 for challenging the denial of the claim;

(3) A summary of any applicable process established pursuant to NRS 687B.820 for challenging the denial of the claim;

12.5.

NRS 695C.050 is hereby amended to read as follows:

695C.050 1.

Except as otherwise provided in this chapter or in specific provisions of this title, the provisions of this title are not applicable to any health maintenance organization granted a certificate of authority under this chapter.

This provision does not - 83rd Session (2025) – 22 – apply to an insurer licensed and regulated pursuant to this title except with respect to its activities as a health maintenance organization authorized and regulated pursuant to this chapter.

2.

Solicitation of enrollees by a health maintenance must not be construed to violate any provision of law relating toatives, solicitation or advertising by practitioners of a healing art.

3.

Any health maintenance organization authorized under this chapter shall not be deemed to be practicing medicine and is exempt from the provisions of chapter 630 of NRS.

4.

The provisions of NRS 695C.110, 695C.125, 695C.1691, 695C.1693, 695C.170, 695C.1703, 695C.1705, 695C.1709 to 695C.173, inclusive, 695C.1733, 695C.17335, 695C.1734, 695C.1751, 695C.1755, 695C.1759, 695C.176 to 695C.200, inclusive, and 695C.265 do not apply to a health maintenance organization that provides health care services through managed care to recipients of Medicaid under the State Plan for Medicaid or insurance pursuant to the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Health and Human Services.

This subsection does not exempt a health maintenance organization from any provision of this chapter for services provided pursuant to any other contract.

5.

The provisions of NRS 695C.16932 to 695C.1699, inclusive, 695C.1701, 695C.1708, 695C.1728, 695C.1731, 695C.17333, 695C.17345, 695C.17347, 695C.1736 to 695C.1745, inclusive, 695C.1757 and 695C.204 apply to a health maintenance care to recipients of Medicaid under the State Plan for Medicaid.

6.

The provisions of NRS 695C.17095 and 695C.187 do not apply to a health maintenance organization that provides health care services to members of the Public Employees’ Benefits Program.

This subsection does not exempt a health maintenance organization from any provision of this chapter for services provided pursuant to any other contract.

7.

The provisions of NRS 695C.1735 do not apply to a health maintenance organization that provides health care services to:

(a) The officers and employees, and the dependents of officers and employees, of the governing body of any county, school district, municipal corporation, political subdivision, public corporation or other local governmental agency of this State;

or (b) Members of the Public Employees’ Benefits Program.

- 83rd Session (2025) – 23 – organization from any provision of this chapter for services provided pursuant to any other contract.

Sec.

- *AB52_R1* – 21 – 2.

Any contract, agreement or other arrangement between a health maintenance organization and a provider that is entered into or renewed on or after [October] JulyJanuary 1, [2001,] 2025,2026, that does not specifically include a provision concerning the schedule for the payment of claims as required by subsection 1 shall be deemed to conform with the requirements of subsection 1 by operation of law.

(b) Denies the claim, notify the claimant in writing of the denial within 21 days after the organization for dental care receives the claim, if the claim was submitted electronically, or 30 days after the organization for dental care receives the claim, ifif30 the claim was not submitted electronically.

(2) The criteria by which the organization for dental care determines whether to approve or deny the claim and a description - 83rd Session (2025) – 24 – of the manner in which the organization for dental care applied those criteria to the claim;

2.approved claim is not paid within [that] the period [,] specified by subsection 1, the organization for dental care shall pay interest on the claim at the rate of [interest established pursuant to NRS 99.040.] 10 percent per annum.

Except as otherwise provided in this section, if the approved claim is not paid within [that] the period [,] specified by subsection 1, the organization for dental care shall pay interest on the claim at the rate of [interest established pursuant to NRS 99.040.] 10 percent per annum.

The organization for dental care shall notify the [provider of dental care] claimant of - *AB52_R1* – 22 – the reason for the delay in approving or denying the claim.

(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 received electronically.

6.- 83rd Session (2025) – 25 – claim that has been approved and is fully payable.ay only part of a 7.

An organization for dental care shall not pay only part of a claim that has been approved and is fully payable.

7.

If the Commissioner determines that an organization for dental care is not in substantial compliance with the requirements set forth in this section or has failed to approve or deny a claim or - *AB52_R1* – 23 – pay an approved claim within 60 working days after receiving thetheim or claim, the Commissioner may require the organization for dental care to pay an administrative fine in an amount to be determined by the Commissioner.

Upon a second or subsequent determination that an organization for dental care 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 authority of the organization for dental care.

The report must include, without limitation:lim(a) The number of claims for which the organization for dental care failed to comply with the requirements of subsections 1 and 3 during the immediately preceding calendar year;

(a) The number of claims for which the organization for dental care failed to comply with the requirements of subsections 1 and 3 during the immediately preceding calendar year;

- 83rd Session (2025) – 26 – Sec.

If a prepaid limited health service organization denies a claim, the prepaid limited health service organization shall notify the(a) Twenty-one days after the claimantprepaid inlimited writinghealth ofservice organization receives all information necessary to make a determination concerning the denialclaim, within:if the information is submitted electronically;

(a) Twenty-one days after the prepaid limited health service organization receives all information necessary to make a determination concerning the claim, if the information is submitted electronically;

and - *AB52_R1* – 24 – (c) A summary of any applicable process established pursuant to NRS 687B.820 for challenging the denial of the claim.

1.439B.754, a managed care organization shall approve or deny a claim within 21 days after the managed care organization receives the claim, if the claim is submitted electronically, or 30 days after the managed care organization receives the claim, if the claim is not submitted electronically.

Except as otherwise provided in subsection 2 and NRS 439B.754, a managed care organization shall approve or deny a claim within 21 days after the managed care organization receives the claim, if the claim is submitted electronically, or 30 days after the managed care organization receives the claim, if the claim is not submitted electronically.

If the managed care organization requires additional information to determine whether to approve or deny the claim, it shall notify the claimant of its request for the additional - 83rd Session (2025) – 27 – information within 20 working days after it receives the claim.

The managed care organization shall approve or deny the claim within 21 days after receiving the additional information, if the additional information is submitted electronically, or 30 days after receiving the additional information, if the additional information is not submitted electronically.

- *AB52_R1* – 25 – 6.

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 beyondbey7.d theThe controlconCommissionermanagmaycarrequireizaa ofmanaged care organization to provide evidence which demonstrates that the managed care organization.organization 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.

7.

The Commissioner may require a managed care organization to provide evidence which demonstrates that the managed care organization 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.

Upon a second or subsequent determination that a managed care organization is not in- substantial83rd complianceSession with(2025) the– requirements28 set– forth in this section or has failed to approve or deny a claim or pay ananin this approved claim within 60 working days after receiving the claim, the Commissioner may suspend or revoke the certificate of authority of the managed care organization.

(a) The number of claims for which the managed care organization failed to comply with the requirements of subsections 1 and 2 during the immediately preceding calendar year;

(Deleted by amendment.) Sec.follows:17.5.

NRS 695G.090 is hereby amended to read as 695G.090 1.

Except as otherwise provided in subsection 3, the provisions of this chapter apply to each organization and insurer that operates as a managed care organization and may include, without limitation, an insurer that issues a policy of health insurance, an insurer that issues a policy of individual or group health insurance, a carrier serving small employers, a fraternal benefit society, a hospital or medical service corporation and a health maintenance organization.

2.

In addition to the provisions of this chapter, each managed care organization shall comply with:

(a) The provisions of chapter 686A of NRS, including all obligations and remedies set forth therein;

and (b) Any other applicable provision of this title.

3.

The provisions of NRS 695G.127, 695G.1639, 695G.164, section 16 of this act do not apply to a managed care organization that provides health care services to recipients of Medicaid under the State Plan for Medicaid or insurance pursuant to the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Health and Human Services.

4.

The provisions of NRS 695C.1735 , [and] 695G.1639 and 695G.230 and section 16 of this act do not apply to a managed care - 83rd Session (2025) – 29 – Public Employees’ Benefits Program.are services to members of the 5.

Subsections 3 and 4 do not exempt a managed care organization from any provision of this chapter for services provided pursuant to any other contract.

Sec.

- *AB52_R1* – 26 – (b) Any time that the health carrier denies coverage of a health care service or limits coverage of a health care service to an insured;

and (c)2.) AnyAIf othera timehealth deemedcarrier necessarydenies bycoverage of a health care service to an insured, including, without limitation, a [health maintenance] managed care organization that denies a claim related to a health care plan pursuant to [NRS 695C.185,] section 16 of this act, it shall notify the Commissioner.insured and, if applicable, the provider of health care who submitted the claim, in writing within :

2.

If a health carrier denies coverage of a health care service to an insured, including, without limitation, a [health maintenance] managed care organization that denies a claim related to a health care plan pursuant to [NRS 695C.185,] section 16 of this act, it shall notify the insured and, if applicable, the provider of health care who submitted the claim, in writing within :

The notice required pursuant to subsection 2 must include, wit(a) [The reason] All reasons for denying coverage of the service [;] , including, without limitation:limitation, the specific facts and provisions of the plan relied upon by the health carrier as a basis to deny coverage of the service;

(a) [The reason] All reasons for denying coverage of the service [;] , including, without limitation, the specific facts and provisions of the plan relied upon by the health carrier as a basis to deny coverage of the service;

(c)- A83rd summarySession of(2025) any– applicable30 process– established pursuant to NRS 687B.820 for challenging the denial of the claim;claim;ursuant (d) The right of the insured to:

(d) The right of the insured to:

-Commissioner *AB52_R1*pursuant –to 27subsection –1 [3.]shall 4.be deemed to be ine clear and comprehensible language that is understandable to an ordinary layperson.

A written notice which is approved by the Commissioner pursuant to subsection 1 shall be deemed to be in clear and comprehensible language that is understandable to an ordinary layperson.

(a) All reasons for denying the claim, including, without limitation,by the specifichealth factscarrier andas provisionsa basis to deny coverage of the planservice;upon relied(b) uponThe criteria by which the health carrier asdetermines awhether basis to approve or deny coveragethe claim and a description of the service;manner in which the health carrier applied those criteria to the claim;

(b) The criteria by which the health carrier determines whether to approve or deny the claim and a description of the manner in which the health carrier applied those criteria to the claim;

- 83rd Session (2025) – 31 – Sec.

19.18.5.

NRS 287.04335 is hereby amended to read as follows:

287.04335 If the Board provides health insurance through a plan of self-insurance, it shall comply with the provisions of NRS 439.581 to 439.597, inclusive, 686A.135, 687B.352, 687B.409, 687B.692, 687B.723, 687B.725, 687B.805, 689B.0353, [689B.255,] 695C.1723, 695G.150, 695G.155, 695G.160, 695G.162, 695G.1635, 695G.164, 695G.1645, 695G.1665, 695G.167, 695G.1675, 695G.170 to 695G.1712, inclusive, 695G.1714 to 695G.174, inclusive, 695G.176, 695G.177, 695G.200 [to 695G.230, inclusive] , 695G.210, 695G.220, 695G.241 to as an insurer that is licensed pursuant to title 57 of NRS is required to comply with those provisions.

Secs.

19-22.

20.

(Deleted by amendment.) Sec.

21.

(Deleted by amendment.) Sec.

22.

(Deleted by amendment.) Sec.

The amendatory provisions of this act do not supersede the provisions of any contract entered into or policy issued before JulyJanuary 1, 2025,2026, but apply to any renewal of such a contract or policy.

The amendatory provisions of this act do not apply to any claim under a policy of health insurance or other program that provides health coverage submitted before JulyJanuary 1, 2025,2026, but, except as otherwise provided in subsection 1, apply to such claims submitted on or after that date.

This act becomes effective on JulyJanuary 1, 2025.2026.

-~~~~~ *AB52_R1*25 –- 2883rd –Session TEXT(2025) OF REPEALED SECTIONS state programs:

Payment of interest on claims.pursuaAny contract or other agreement entered into or renewed by a health maintenance organization on or after October 1, 2001:

1.

To provide health care services through managed care to recipients of Medicaid under the state plan for Medicaid;

or 2.

With the Division of Health Care Financing and Policy of the Department of Health and Human Services to provide insurance pursuant to the Children’s Health Insurance Program,  must require the health maintenance organization to pay interest to a provider of health care services on a claim that is not paid within the time provided in the contract or agreement at a rate of ascertained by the Commissioner of Financial Institutions, ona, as January 1 or July 1, as the case may be, immediately preceding the date on which the payment was due, plus 6 percent.

The interest must be calculated from 30 days after the date on which the claim is approved until the date on which the claim is paid.

695C.185 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 authority for failure to comply.

1.

Except as otherwise provided in subsection 2 and NRS 439B.754, a health maintenance organization shall approve or deny maintenance organization receives the claim.

If the claim isthe health approved, the health maintenance organization shall pay the claim within 30 days after it is approved.

Except as otherwise provided in this section, if the approved claim is not paid within that period, the health maintenance organization shall pay interest on the claim at a rate of interest equal to the prime rate at the largest bank in Nevada, as ascertained by the Commissioner of Financial Institutions, on January 1 or July 1, as the case may be, immediately preceding the date on which the payment was due, plus 6 percent.

The interest must be calculated from 30 days after the date on which the claim is approved until the date on which the claim is paid.

2.

If the health maintenance organization requires additional information to determine whether to approve or deny the claim, it - *AB52_R1* – 29 – shall notify the claimant of its request for the additional information within 20 days after it receives the claim.

The health maintenance organization shall notify the provider of health care services of all the specific reasons for the delay in approving or denying the claim.

The health maintenance organization shall approve or deny the claim within 30 days after receiving the additional information.

If the claim is approved, the health maintenance organization shall pay the claim within 30 days after it receives the additional information.

If the approved claim is not paid within that period, the health maintenance organization shall pay interest on the claim in the manner prescribed in subsection 1.

claimant to resubmit information that the claimant has already provided to the health maintenance organization, unless the health maintenance organization 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.

4.

A health maintenance organization shall not pay only part of a claim that has been approved and is fully payable.

5.

A court shall award costs and reasonable attorney’s fees to the prevailing party in an action brought pursuant to this section.

6.

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 bey7.

The Commissioner may require a health maintenanceon.

organization to provide evidence which demonstrates that the health maintenance organization has substantially complied with the requirements set forth in this section, including, without limitation, payment within 30 days of at least 95 percent of approved claims or at least 90 percent of the total dollar amount for approved claims.

8.

If the Commissioner determines that a health maintenance organization is not in substantial compliance with the requirements set forth in this section, the Commissioner may require the health maintenance organization to pay an administrative fine in an amount to be determined by the Commissioner.

Upon a second or subsequent determination that a health maintenance organization is section, the Commissioner may suspend or revoke the certificate ofhis authority of the health maintenance organization.

H - *AB52_R1*