Below are Nevada’s workers’ compensation laws and regulations on payment denials and appeals.
Payment Denial - Unrelated Services
Payment Denial - Authorization
Payment Denial - Unrelated Services
Nevada Revised Statutes § 616C.137 - Denial of payment for unrelated services: Requirements for notification; liability of injured employee; appeal.
1. If an insurer, organization for managed care or employer who provides accident benefits for injured employees pursuant to NRS 616C.265 denies payment for some or all of the services itemized on a statement submitted by a provider of health care on the sole basis that those services were not related to the employee’s industrial injury or occupational disease, the insurer, organization for managed care or employer shall, at the same time that it sends notification to the provider of health care of the denial, send a copy of the statement to the injured employee and notify the injured employee that it has denied payment.
The notification sent to the injured employee must:
(a) State the relevant amount requested as payment in the statement, that the reason for denying payment is that the services were not related to the industrial injury or occupational disease and that, pursuant to subsection 2, the injured employee will be responsible for payment of the relevant amount if the injured employee does not, in a timely manner, appeal the denial pursuant to NRS 616C.315 to 616C.385, inclusive, or appeals but is not successful.
(b) Include an explanation of the injured employee’s right to request a hearing to appeal the denial pursuant to NRS 616C.315 to 616C.385, inclusive, and a suitable form for requesting a hearing to appeal the denial.
2. An injured employee who does not, in a timely manner, appeal the denial of payment for the services rendered or who appeals the denial but is not successful is responsible for payment of the relevant charges on the itemized statement.
3. To succeed on appeal, the injured employee must show that the:
(a) Services provided were related to the employee’s industrial injury or occupational disease; or
(b) Insurer, organization for managed care or employer who provides accident benefits for injured employees pursuant to NRS 616C.265 gave prior authorization for the services rendered and did not withdraw that prior authorization before the services of the provider of health care were rendered.
Payment Denial - Authorization
Nevada Revised Statutes § 616C.138 - Payment of provider of health care upon insurer’s denial of authorization or responsibility for treatment or other services provided; reimbursement of injured employee or health or casualty insurer; reimbursement from health or casualty insurer; recovery of excess amount paid to provider of health care.
1. Except as otherwise provided in this section and NRS 616C.091, if a provider of health care provides treatment or other services that an injured employee alleges are related to an industrial injury or occupational disease and an insurer, an organization for managed care, a third-party administrator or an employer who provides accident benefits for injured employees pursuant to NRS 616C.265 denies authorization or responsibility for payment for the treatment or other services, the provider of health care is entitled to be paid for the treatment or other services as follows:
(a) If the treatment or other services will be paid by a health insurer which has a contract with the provider of health care under a health benefit plan that covers the injured employee, the provider of health care is entitled to be paid the amount that is allowed for the treatment or other services under that contract.
(b) If the treatment or other services will be paid by a health insurer which does not have a contract with the provider of health care as set forth in paragraph (a) or by a casualty insurer or the injured employee, the provider of health care is entitled to be paid not more than:
(1) The amount which is allowed for the treatment or other services set forth in the schedule of fees and charges established pursuant to NRS 616C.260; or
(2) If the insurer which denied authorization or responsibility for the payment has contracted with an organization for managed care or with providers of health care pursuant to NRS 616B.527, the amount that is allowed for the treatment or other services under that contract.
2. The provisions of subsection 1:
(a) Apply only to treatment or other services provided by the provider of health care before the date on which the insurer, organization for managed care, third-party administrator or employer who provides accident benefits first denies authorization or responsibility for payments for the alleged industrial injury or occupational disease.
(b) Do not apply to a provider of health care that is a hospital as defined in NRS 439B.110. The provisions of this paragraph do not exempt the provider of health care from complying with the provisions of subsections 3 and 7.
Bill Payment Review & Appeal
Nevada Administrative Code § 616C.027 - Review of reduction, denial or nonpayment of bill; appeal of determination upon review.
1. A provider of health care whose bill has been denied or reduced or is not paid in a timely manner may, within 60 days after receiving notice of the denial or reduction, or within 60 days after the payment was due, submit a written request to the Workers’ Compensation Section for a review of that action.
The request must identify the billed item for which the review is sought and state the ground upon which the request is based.
The Workers’ Compensation Section shall review the matter, and if it determines that issuing a written determination is appropriate, it shall issue a written determination and mail or deliver copies of the determination to the provider of health care and the insurer. If the determination is in the provider’s favor, the insurer shall, within 30 days after receiving notice of the determination, pay the bill, unless an appeal is taken in the manner provided by subsection 2.
2. A provider of health care or insurer aggrieved by the determination of the Workers’ Compensation Section may file a request for a hearing before an appeals officer. The request must be filed within 30 days after the date of the determination.
3. The provider of health care and the insurer will be the only parties to the hearing scheduled pursuant to subsection 2.
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