Below are the Nevada workers’ compensation requirements for prior authorization.
Requesting Authorization & Insurer Response Timeliness
Occupational Medicine Practice Guidelines
Out-Of-State Treatment Authorization
When to Request Authorization
Nevada Administrative Code § 616C.129 - Adherence to rules for treatment of injured employees by members of panel of physicians and chiropractic physicians.
5. The treating physician or chiropractic physician must request written authorization from the insurer before ordering or performing any one of the following services with an estimated billed amount of $200 or more:
(a) Consultation;
(b) Diagnostic testing;
(c) Elective hospitalization;
(d) Any surgery which is to be performed under circumstances other than an emergency; or
(e) Any elective procedure.
6. Any request for prior authorization to order or perform any of the services set forth in subsection 5 must contain an explanation of the need for each service to be ordered or performed. If any of the services are performed without the insurer’s written authorization, the insurer is not liable for the fee for the service, unless good cause is shown for providing the services without prior authorization.
7. A treatment program that consists of more than six visits, not including the initial evaluation, and is billed under codes 97010 to 97799, inclusive, or 98925 to 98943, inclusive, whether the visits are billed separately or included under different codes, must be authorized in advance by the insurer to verify the medical necessity for continued treatment. The first six visits do not require the prior authorization of the insurer. The number of requests for additional visits by the treating physician or chiropractic physician and any written authorization granted therefor are not restricted, and are subject only to the treatment prescribed by the treating physician or chiropractic physician and the determination of the insurer. A report of the status of an injured employee may be requested by an insurer at any time during the course of treatment. The initial evaluation shall be deemed to be separate from the initial six treatments. An initial evaluation may be performed on the same day as the initial treatment.
Exception - Emergencies
Nevada Administrative Code § 616C.126 - Treatment of injured employees in cases of emergency or severe trauma.
1. The treatment of injured employees in cases of an emergency or severe trauma is not restricted to physicians and chiropractic physicians who:
(a) Are members of the panel of physicians and chiropractic physicians established by the Administrator pursuant to NRS 616C.090; or
(b) Have contracted with an insurer or an organization for managed care to provide health care services to injured employees.
2. In the case of a medical emergency, a provider of health care or a medical facility that is not able to obtain prior written authorization to treat a person for an industrial injury or occupational disease shall submit to the insurer proof of the emergency and the reasons why prior authorization was impracticable to obtain. The proof must be submitted with the initial billing for the treatment that was rendered.
Requesting Authorization & Insurer Response Timeliness
Nevada Revised Statutes § 616C.157 - Request for prior authorization: Time to respond; effect of failure to respond in timely manner.
1. An insurer, organization for managed care or third-party administrator shall respond to a written request for prior authorization for:
(a) Treatment;
(b) Diagnostic testing; or
(c) Consultation,
within 5 working days after receiving the written request.
2. If the insurer, organization for managed care or third-party administrator fails to respond to such a request within 5 working days, authorization shall be deemed to be given. The insurer, organization for managed care or third-party administrator may subsequently deny authorization.
3. If the insurer, organization for managed care or third-party administrator subsequently denies a request for authorization submitted by a provider of health care for additional visits or treatments, it shall pay for the additional visits or treatments actually provided to the injured employee, up to the number of treatments for which payment is requested by the provider of health care before the denial of authorization is received by the provider.
Occupational Medicine Practice Guidelines
Nevada Administrative Code 616C.123 - Occupational Medicine Practice Guidelines: Adoption by reference; annual review by Administrator; use as minimum standards; authorization for treatment exceeding minimum standards.
1. The most recently published edition of or update to the Occupational Medicine Practice Guidelines, developed by the American College of Occupational and Environmental Medicine and published by the Reed Group, Ltd., is hereby adopted by reference as standards for the provision of accident benefits to employees who have suffered industrial injuries or occupational diseases.
2. The Administrator will, on or before February 1 of each year, review the most recently published edition of or update to the Guidelines. Each new edition of or update to the Guidelines shall be deemed approved by the Administrator for use in this State on February 1 of each year, unless a notice of disapproval of the edition or update is posted pursuant to this subsection by the immediately preceding April 1. If the Administrator wishes to disapprove a new edition of or update to the Guidelines, the Administrator will:
(a) Post a notice of disapproval at the largest public library in each county, the State Library, Archives and Public Records, the Grant Sawyer Office Building located at 555 East Washington Avenue, Las Vegas, Nevada, and all offices of the Division; and
(b) Send a notice to each person included on the mailing list that the Division is required to maintain pursuant to paragraph (e) of subsection 1 of NRS 233B.0603. If the Administrator disapproves an edition of or update to the Guidelines, the edition or update that was most recently adopted by reference or deemed approved pursuant to this section will continue in effect.
3. Except as otherwise provided in this subsection, insurers and providers of health care shall use the Guidelines as minimum standards for evaluating and ensuring the quality of programs of treatment provided to an injured employee who is entitled to accident benefits pursuant to chapters 616A to 617, inclusive, of NRS. If a condition of the injured employee makes compliance with the Guidelines impossible, medically inadvisable or not recommended by a physician or chiropractic physician who:
(a) Is employed by or works pursuant to a contract with the insurer or its third-party administrator or organization for managed care to provide medical advice on claims;
(b) Is licensed to practice in this State;
(c) Possesses the education, training and expertise necessary to evaluate the medical condition of the injured employee or obtains the advice or assistance necessary to evaluate the medical condition of the employee;
(d) Has reviewed the notes of the treating physician or chiropractic physician, the results of any tests conducted by the treating physician or chiropractic physician and any relevant health care records of the injured employee; and
(e) Recommends to the insurer not to authorize treatment pursuant to the Guidelines, the insurer may determine not to authorize treatment pursuant to the Guidelines.
4. An insurer may authorize treatment for an injured employee that exceeds the minimum standards of the Guidelines if the provider of health care provides, in writing, to the insurer the explanation for the need of a higher standard of treatment.
5. A copy of the Guidelines may be purchased from the Reed Group, Ltd., 10355 Westmoor Drive, Westminster, Colorado 80021, by telephone at (866) 889-4449 or by electronic mail at guidelines_sales@reedgroup.com, at a cost of $675 for a single-user license.
6. As used in this section, the term “Guidelines” means the Occupational Medicine Practice Guidelines adopted by reference pursuant to subsection 1.
Out-Of-State Treatment Authorization
Nevada Administrative Code § 616C.143 - Consultation or treatment provided outside State: Prior written authorization; treatment in cases of emergency.
1. Except as otherwise provided in this section, an insurer is not financially liable for consultation or treatment that is provided outside this State unless the insurer has given prior written authorization to the provider of health care or the medical facility in which the consultation or treatment is provided for the consultation or treatment. At the time of giving the written authorization, the insurer shall give written notice, which must include the date on which the notice is given, to the injured employee and the provider of health care or the medical facility that:
(a) The payment for the consultation or treatment will be made in accordance with the schedule of reasonable fees and charges allowable for accident benefits adopted for this State pursuant to NRS 616C.260, unless otherwise provided in a contract between the provider of health care or the medical facility and the insurer;
(b) The insurer is solely responsible for the payment of all services rendered;
(c) The injured employee is not financially liable for any part of the cost of the services rendered and must not be billed for those services; and
(d) Any bill must be submitted within 90 days after services are rendered.
2. Prior authorization for treatment that is provided outside this State in cases of an emergency is not required. A provider of health care or a medical facility that renders such treatment to an injured employee subject to the provisions of chapters 616A to 616D, inclusive, or chapter 617 of NRS must bill for such services using the appropriate coding found in the American Medical Association’s “Physician’s Current Procedural Terminology” as contained in the Relative Values for Physicians, as adopted by reference in NAC 616C.145. The provider of health care or medical facility shall submit a bill for all such treatment and include the fees as set forth in the schedule of reasonable fees and charges allowable for accident benefits, if any, of the state in which the treatment was rendered or the usual and customary fees of the provider or medical facility, whichever are less.
3. The insurer shall pay for treatment that is provided outside this State in cases of an emergency according to the billing received, unless the fee is unreasonable. A fee shall be deemed to be reasonable if it is provided in accordance with the provisions of this section.
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