Nevada Assembly Bill AB290 Amended / Bill

                     	EXEMPT 
 (Reprinted with amendments adopted on April 21, 2025) 
 	FIRST REPRINT A.B. 290 
 
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ASSEMBLY BILL NO. 290–ASSEMBLYMEMBERS NGUYEN, 
CONSIDINE, NADEEM, YUREK, BROWN-MAY; ANDERSON, 
COLE, D’SILVA, EDGEWORTH, GONZÁLEZ, GOULDING, 
KARRIS, KOENIG, KASAMA AND MOSCA 
 
FEBRUARY 25, 2025 
____________ 
 
JOINT SPONSORS: SENATORS FLORES, NEAL, NGUYEN AND TAYLOR 
____________ 
 
Referred to Committee on Commerce and Labor 
 
SUMMARY—Revises provisions relating to prior authorization for 
medical or dental care under health insurance plans. 
(BDR 57-861) 
 
FISCAL NOTE: Effect on Local Government: May have Fiscal Impact. 
 Effect on the State: Yes. 
 
CONTAINS UNFUNDED MANDATE (§ 22) 
(NOT REQUESTED BY AFFECTED LOCAL GOVERNMENT) 
 
~ 
 
EXPLANATION – Matter in bolded italics is new; matter between brackets [omitted material] is material to be omitted. 
 
 
AN ACT relating to insurance; imposing requirements governing 
prior authorization for medical or dental care; prohibiting 
an insurer from requiring prior authorization for covered 
emergency services or denying coverage for covered, 
medically necessary emergency services; requiring an 
insurer to publish certain information relating to requests 
for prior authorization on the Internet; requiring an insurer 
and the Commissioner of Insurance to compile certain 
reports; and providing other matters properly relating 
thereto. 
Legislative Counsel’s Digest: 
 Existing law authorizes certain health insurers to require prior authorization 1 
before an insured may receive coverage for health and dental care in certain 2 
circumstances. If an insurer requires prior authorization, existing law requires the 3 
insurer to: (1) file its procedure for obtaining prior authorization with the 4 
Commissioner of Insurance for approval; and (2) respond to a request for prior 5 
authorization within 20 days after receiving the request. (NRS 687B.225) This bill 6   
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establishes additional requirements relating to the use of prior authorization for 7 
health and dental care by health insurers, including insurance for public employees 8 
as well as specific requirements relating to prior authorization under Medicaid and 9 
the Children’s Health Insurance Program (CHIP). 10 
 Specifically, sections 19 and 34 of this bill require that a procedure for 11 
obtaining prior authorization includes: (1) a list of the items and services for which 12 
the insurer requires prior authorization; and (2) the clinical review criteria used by 13 
the insurer to evaluate requests for prior authorization. Sections 19 and 34 also 14 
require an insurer to publish its procedure for obtaining prior authorization on its 15 
Internet website. Sections 19 and 34 prohibit an insurer from denying a claim for 16 
payment for medical or dental care because of the failure to obtain prior 17 
authorization if the insurer’s procedures for obtaining prior authorization in effect 18 
on the date that the care was provided did not require prior authorization for that 19 
care. 20 
 Section 12.5 of this bill requires insurers, other than those covering recipients 21 
of Medicaid and CHIP, which employ or utilize an artificial intelligence system or 22 
automated decision tool to process requests for prior authorization to transmit a 23 
notice to each insured that: (1) discloses the insurer’s use of the system or tool to 24 
process requests for prior authorization; and (2) describes certain aspects of the 25 
system or tool. Section 12.5 also prohibits an insurer from using an artificial 26 
intelligence system or automated decision tool to make an adverse determination on 27 
a request for prior authorization, or to terminate, reduce or modify a previously 28 
approved request for prior authorization, unless that action is independently 29 
reviewed by a physician or dentist, as applicable, who possesses certain 30 
qualifications. 31 
 Section 19 requires an insurer, other than an insurer covering recipients of 32 
Medicaid or CHIP, to approve or make an adverse determination on a request for 33 
prior authorization, or request additional, medically relevant information within: (1) 34 
7 days after receiving the request, for medical or dental care that is not urgent; or 35 
(2) 48 hours after receiving the request, for care that is urgent. Section 35 of this 36 
bill requires entities providing coverage under Medicaid or CHIP, including 37 
Medicaid managed care organizations, to approve, make an adverse determination 38 
on or request additional, medically relevant information for any request for prior 39 
authorization, except for requests for prescription drugs and certain other services, 40 
within 7 days after receiving the request. Sections 13 and 36 of this bill require any 41 
adverse determination on a request for prior authorization to be made by certain 42 
authorized providers of health care. Section 13 requires an insurer, other than those 43 
covering recipients of Medicaid or CHIP, to, in certain circumstances, allow the 44 
provider of health care who requested the prior authorization, or certain colleagues 45 
of the provider, to discuss the issues involved in the request with the physician or 46 
dentist who is responsible for making a determination on the request. Sections 13 47 
and 36 require an insurer, upon making an adverse determination on a request for 48 
prior authorization, to transmit certain information to the insured to whom the 49 
request pertains, including information relating to the right of the insured to appeal 50 
the adverse determination. Section 13 requires: (1) an insurer, other than those 51 
covering recipients of Medicaid or CHIP, to establish a process for appeals that 52 
provides for the timely resolution of appeals submitted by insureds; and (2) a 53 
decision upholding an adverse determination on an appeal submitted by an insured 54 
to be made by a physician or dentist who has qualifications beyond those required 55 
of a physician or dentist who evaluates initial requests for prior authorization.  56 
 Section 36 establishes certain other requirements for appeals of adverse 57 
determinations pertaining to recipients of Medicaid and CHIP. 58 
 Section 14 of this bill: (1) provides that a request for prior authorization that 59 
has been approved by an insurer, other than an insurer covering recipients of 60 
Medicaid or CHIP, remains valid for 12 months, if the approval is for a continuous 61   
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course of care relating to a chronic or long-term condition, or 6 months for other 62 
medical or dental care; and (2) requires such an insurer, for the first 90 days of the 63 
coverage period for a new insured, to honor a request for prior authorization that 64 
has been approved by the previous insurer of the new insured, under certain 65 
circumstances. Section 37 of this bill provides that a request for prior authorization 66 
approved for recipients of Medicaid and CHIP remains valid for 12 months after 67 
approval, unless federal law provides for a different amount of time. 68 
 Sections 15 and 38 of this bill prohibit an insurer from requiring prior 69 
authorization for covered emergency services. Sections 15 and 38 also prohibit an 70 
insurer from requiring that an insured or provider of health care notify the insurer 71 
earlier than the end of the business day following the date of admission or the date 72 
on which the emergency services are provided. Additionally, section 38: (1) 73 
prohibits an insurer covering recipients of Medicaid and CHIP from denying 74 
coverage for covered medically necessary emergency services; and (2) establishes a 75 
presumption of such medical necessity under certain conditions. 76 
 Sections 3-12 and 27-32 of this bill define certain terms relating to the process 77 
of obtaining and processing requests for prior authorization, and sections 2 and 26 78 
of this bill establish the applicability of those definitions. Section 16 of this bill 79 
provide that if an insurer, other than an insurer covering recipients of Medicaid or 80 
CHIP, violates any provision of section 12.5-15 or 19 with respect to a particular 81 
request for prior authorization, that the request is deemed approved. Sections 16 82 
and 39 of this bill clarify that nothing in any provision of section 12.5-15, 19 or 83 
34-38 require an insurer to provide coverage: (1) for care that the insurer does not 84 
cover, regardless of the medical necessity of the care; or (2) to persons to whom the 85 
insured is not obligated to provide coverage. 86 
 Section 17 of this bill requires an insurer, other than an insurer covering 87 
recipients of Medicaid or CHIP, to annually publish on its Internet website and 88 
submit to the Commissioner of Insurance certain information relating to requests 89 
for prior authorization that have been processed by the insurer during the 90 
immediately preceding year. Section 17 additionally requires the Commissioner to 91 
biennially transmit to the Legislature the data collected from insurers for the 92 
biennium and a report summarizing the data. Sections 40 and 41 of this bill impose 93 
similar reporting requirements on entities providing coverage for recipients and 94 
CHIP relating to requests for prior authorization received by those entities. 95 
 Section 20 of this bill requires a nonprofit hospital and medical or dental 96 
service corporation to comply with sections 2-17. Section 21 of this bill requires 97 
the Director of the Department of Health and Human Services to administer the 98 
provisions of sections 26-41 of this bill in the same manner as other provisions 99 
governing Medicaid. Sections 22, 23 and 44 of this bill require plans of self-100 
insurance for employees of local governments, the Public Employees’ Benefits 101 
Program and plans of self-insurance for private employers, respectively, to comply 102 
with the requirements of sections 2-19 of this bill to the extent applicable. Sections 103 
12.2 and 34 of this bill provide that a managed care organization that provides 104 
services to recipients of Medicaid or the Children’s Health Insurance Program is 105 
subject to the requirements of sections 26-41, and is not required to comply with 106 
sections 2-19. Section 42 of this bill requires the policies and procedures for 107 
coverage for prescription drugs under Medicaid to comply with sections 26-41. 108 
Section 47.5 of this bill repeals provisions establishing certain requirements 109 
relating to prior authorization for dental care which sections 2-19 make redundant. 110 
 
 
   
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THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN 
SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS: 
 
 Section 1.  Chapter 687B of NRS is hereby amended by adding 1 
thereto the provisions set forth as sections 2 to 18, inclusive, of this 2 
act. 3 
 Sec. 2.  As used in NRS 687B.225 and sections 2 to 18, 4 
inclusive, of this act, unless the context otherwise requires, the 5 
words and terms defined in sections 3 to 12, inclusive, of this act 6 
have the meanings ascribed to them in those sections. 7 
 Sec. 3.  “Adverse determination” means a determination by a 8 
health carrier that an admission or other medical care or dental 9 
care that is a covered benefit has been reviewed and, based upon 10 
the information provided, does not meet the health carrier’s 11 
requirements for medical necessity, appropriateness, health care 12 
setting, level of care or effectiveness, and the requested care or 13 
service or payment for the care or service is therefore denied.  14 
 Sec. 4.  “Emergency services” means health care services 15 
that are provided by a provider of health care to screen and to 16 
stabilize an insured after the sudden onset of a medical condition 17 
that manifests itself by symptoms of such sufficient severity that a 18 
prudent person would believe that the absence of immediate 19 
medical attention could result in: 20 
 1. Serious jeopardy to the health of the insured; 21 
 2. Serious jeopardy to the health of a fetus of the insured; 22 
 3. Serious impairment of a bodily function of the insured; or 23 
 4. Serious dysfunction of any bodily organ or part of the 24 
insured. 25 
 Sec. 5.  “Health carrier” has the meaning ascribed to it in 26 
NRS 695G.024, and includes, without limitation, an organization 27 
for dental care. The term additionally includes a utilization review 28 
organization, as defined in NRS 695G.085. 29 
 Sec. 6.  (Deleted by amendment.) 30 
 Sec. 7.  “Insured” means a policyholder, subscriber, enrollee 31 
or other person covered by a policy or contract of health insurance 32 
issued by a health carrier. 33 
 Sec. 8.  “Medically necessary” has the meaning ascribed to it 34 
in NRS 695G.055. 35 
 Sec. 9.  (Deleted by amendment.) 36 
 Sec. 10.  (Deleted by amendment.) 37 
 Sec. 11.  “Provider of health care” has the meaning ascribed 38 
to it in NRS 695G.070. 39 
 Sec. 12.  “Urgent health care”: 40   
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 1. Means health care that, in the opinion of a provider of 1 
health care with knowledge of an insured’s medical condition, if 2 
not rendered to the insured within 48 hours could: 3 
 (a) Seriously jeopardize the life or health of the insured or the 4 
ability of the insured to regain maximum function; or 5 
 (b) Subject the insured to severe pain that cannot be 6 
adequately managed without receiving such care. 7 
 2. Does not include emergency services. 8 
 Sec. 12.2.  NRS 687B.225 and sections 2 to 17, inclusive, of 9 
this act, do not apply to a health maintenance organization or 10 
other managed care organization that enters into a contract with 11 
the Department of Health and Human Services or the Division of 12 
Health Care Financing and Policy of the Department pursuant to 13 
NRS 422.273 to provide health care services to recipients of 14 
Medicaid under the State Plan for Medicaid or insurance under 15 
the Children’s Health Insurance Program to the extent that the 16 
organization is providing such services. 17 
 Sec. 12.5.  1. If a health carrier utilizes an artificial 18 
intelligence system or automated decision tool to process requests 19 
for prior authorization, the health carrier shall make available, in 20 
a place that is readily accessible and conspicuous to insureds and 21 
the public: 22 
 (a) A statement that the health carrier utilizes an artificial 23 
intelligence system or automated decision tool to process requests 24 
for prior authorization; 25 
 (b) A general description of how the artificial intelligence 26 
system or automated decision tool works; and 27 
 (c) A description of the specific types of information or data 28 
utilized by the artificial intelligence system or automated decision 29 
tool to generate an outcome. 30 
 2. Except as otherwise provided in subsection 3, a health 31 
carrier shall not utilize or employ an artificial intelligence system 32 
or automated decision tool to: 33 
 (a) Make an adverse determination on a request for prior 34 
authorization; or 35 
 (b) Terminate, reduce or modify coverage for medical or 36 
dental care that was previously approved by the health carrier. 37 
 3. A health carrier may utilize or employ an artificial 38 
intelligence system or automated decision tool for a purpose 39 
described in subsection 2 if, when the artificial intelligence system 40 
or automated decision tool generates an outcome on a request for 41 
prior authorization, the request is independently reviewed by a 42 
physician or, for a request involving dental care, a dentist, who 43 
meets the requirements set forth in paragraph (a) of subsection 1 44 
of section 13 of this act. 45   
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 4. As used in this section: 1 
 (a) “Artificial intelligence system” means a machine-based 2 
system that can, for a given set of human-defined objectives, make 3 
predictions, recommendations or decisions influencing real or 4 
virtual environments. 5 
 (b) “Automated decision tool” means an automated or 6 
computerized system that is specifically developed or modified to 7 
make, or be a controlling factor in making, consequential 8 
decisions. 9 
 Sec. 13.  1. A health carrier shall not make an adverse 10 
determination on a request for prior authorization unless: 11 
 (a) The adverse determination is made by a physician or, for 12 
dental care, a dentist, who: 13 
  (1) Holds an unrestricted license to practice medicine or 14 
dentistry, as applicable, in any state or territory of the United 15 
States; and 16 
  (2) Has knowledge or training regarding the treatment of 17 
the medical or dental condition involved in the request or has 18 
experience treating or managing the medical or dental condition 19 
involved in the request; and 20 
 (b) The adverse determination is reviewed and affirmed by: 21 
  (1) A medical director of the health carrier or a similar 22 
employee who is in charge of the medical operations of the health 23 
carrier; or 24 
  (2) A physician or, for dental care, a dentist, who: 25 
   (I) Has been designated by the medical director or 26 
similar employee to review the adverse determination; and 27 
   (II) Is employed by or contracted with the health carrier 28 
specifically to perform reviews or appeals of adverse 29 
determinations. 30 
 2. If a physician or dentist described in paragraph (a) of 31 
subsection 1 is considering making an adverse determination on a 32 
request for prior authorization on the basis that the medical or 33 
dental care involved in the request is not medically necessary, the 34 
health carrier that received the request shall: 35 
 (a) Notify the provider of health care who submitted the 36 
request, or the person designated by the provider of health care to 37 
manage requests for prior authorization, that the medical 38 
necessity of the requested care is being questioned by the health 39 
carrier; and 40 
 (b) Offer the provider of health care who submitted the 41 
request, or a colleague of that provider of health care who has the 42 
knowledge and ability to provide additional information with 43 
respect to the request, an opportunity to speak with the physician 44 
or dentist, as applicable, over the telephone or by videoconference 45   
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to discuss the clinical issues involved in the request before the 1 
physician or dentist renders an initial determination on the 2 
request. 3 
 3. Upon rendering an adverse determination on a request for 4 
prior authorization, a health carrier shall immediately transmit to 5 
the insured to whom the request pertains a written notice that 6 
contains: 7 
 (a) A specific description of all reasons that the health carrier 8 
made the adverse determination; 9 
 (b) A description of any documentation that the health carrier 10 
requested from the insured or a provider of health care of the 11 
insured and did not receive or deemed insufficient, if the failure to 12 
receive sufficient documentation contributed to the adverse 13 
determination; 14 
 (c) A statement that the insured has the right to appeal the 15 
adverse determination; 16 
 (d) Instructions, written in clear language that is 17 
understandable to an ordinary layperson, describing how the 18 
insured can appeal the adverse determination through the process 19 
established pursuant to subsection 4; and 20 
 (e) A description of any documentation that may be necessary 21 
or pertinent to a potential appeal. 22 
 4. A health carrier shall establish a process that allows an 23 
insured to appeal an adverse determination on a request for prior 24 
authorization. The process must allow for the clear resolution of 25 
each appeal within a reasonable time. 26 
 5. A health carrier shall not uphold on appeal an adverse 27 
determination pertaining to a request for prior authorization 28 
unless the decision on the appeal is made by a physician or, for 29 
dental care, a dentist, who: 30 
 (a) Holds an unrestricted license to practice medicine or 31 
dentistry, as applicable, in any state or territory of the United 32 
States; 33 
 (b) Has knowledge or training regarding the treatment of the 34 
medical or dental condition involved in the request or has 35 
experience treating or managing the medical or dental condition 36 
involved in the request; 37 
 (c) Was not involved in making the adverse determination that 38 
is the subject of the appeal; 39 
 (d) Considers all known clinical aspects of the medical or 40 
dental care involved in the request; and 41 
 (e) Is employed by or contracted with the health carrier:  42 
  (1) To participate in the network of the health carrier in his 43 
or her capacity as a practicing physician or dentist, as applicable; 44 
or 45   
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  (2) Primarily to make determinations on reviews or appeals 1 
of adverse determinations. 2 
 6. As used in this section: 3 
 (a) “Network” means a defined set of providers of health care 4 
who are under contract with a health carrier to provide health 5 
care services pursuant to a network plan offered or issued by the 6 
health carrier. 7 
 (b) “Network plan” means a contract or policy of insurance 8 
offered by a health carrier under which the financing and delivery 9 
of medical or dental care is provided, in whole or in part, through 10 
a defined set of providers under contract with the health carrier. 11 
 Sec. 14.  1.  Except as otherwise provided in subsection 2, if 12 
a health carrier approves a request for prior authorization and the 13 
process to provide the approved medical or dental care has been 14 
initiated, the approval remains valid until 6 months after the date 15 
on which the request is approved. 16 
 2. Except as otherwise provided in this this subsection, if a 17 
health carrier approves a request for prior authorization for a 18 
continuous course of treatment that relates to a chronic or long-19 
term condition which is specifically identified in the request for 20 
prior authorization, the approval remains valid until 12 months 21 
after the date on which the health carrier approved the request. A 22 
health carrier may require additional prior authorization for 23 
medical or dental care that represents a substantial deviation from 24 
the course of treatment indicated in the previous request for prior 25 
authorization that was approved by the health carrier. 26 
 3. A health carrier shall not revoke or impose an additional 27 
limit, condition or restriction on a request for prior authorization 28 
that the health carrier has previously approved unless: 29 
 (a) The health carrier determines that an insured or a provider 30 
of health care procured the approval by fraud or material 31 
misrepresentation; 32 
 (b) The health carrier determines that the care at issue in the 33 
request was not covered by the health carrier at the time the care 34 
was provided; or 35 
 (c) The coverage period of the policy or contract of insurance 36 
under which the insured was covered at the time of the approval 37 
has ended and the insured is currently covered under a different 38 
policy or contract of insurance which imposes a lower cost-39 
sharing obligation for the relevant medical or dental care. 40 
 4. A health carrier that has approved a request for prior 41 
authorization shall not deny or refuse to promptly pay a claim for 42 
the approved medical or dental care unless the health carrier 43 
determines that the insured or provider of health care procured 44 
the prior authorization by fraud or material misrepresentation.  45   
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 5. Within the first 90 days of the coverage period for an 1 
insured, a health carrier shall honor a request for prior 2 
authorization that has been approved by a health carrier or other 3 
entity that previously provided the insured with coverage for 4 
medical or dental care if: 5 
 (a) The approval was issued within the 6 months immediately 6 
preceding the first day of the coverage period under the current 7 
contract or policy of insurance;  8 
 (b) The insured or his or her provider of health care furnishes 9 
the health carrier with complete documentation with respect to the 10 
prior approval in a timely manner, if the health carrier requests 11 
such documentation; and 12 
 (c) The specific medical or dental care included within the 13 
request is not affirmatively excluded under the terms and 14 
conditions of the contract or policy of insurance issued by the 15 
health carrier. 16 
 6. Nothing in this section shall be construed to prohibit a 17 
health carrier from subsequently reducing or eliminating a cost-18 
sharing obligation imposed against an insured for medical or 19 
dental care for which the health carrier has previously granted 20 
prior authorization. 21 
 7. As used in this section, “coverage period” means the 22 
current term of a contract or policy of insurance issued by a 23 
health carrier. 24 
 Sec. 15.  1. A health carrier shall not require prior 25 
authorization for emergency services covered by the health 26 
carrier, including, where applicable, transportation by ambulance 27 
to a hospital or other medical facility. 28 
 2. If a health carrier requires an insured or his or her 29 
provider of health care to notify the health carrier that the insured 30 
has been admitted to a hospital to receive emergency services or 31 
has received emergency services, the health carrier shall not 32 
require an insured or a provider of health care to transmit such a 33 
notice earlier than the end of the business day immediately 34 
following the day after the date on which the insured was admitted 35 
or the emergency services were provided, as applicable. 36 
 Sec. 16.  1. If a health carrier violates NRS 687B.225 or 37 
section 12.5, 13, 14 or 15 of this act with respect to a particular 38 
request for prior authorization, the request shall be deemed 39 
approved. 40 
 2. Nothing in NRS 687B.225 or sections 12.5 to 15, inclusive, 41 
of this act shall be construed to require a health carrier to provide 42 
coverage: 43   
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 (a) For medical or dental care that, regardless of whether such 1 
care is medically necessary, would not be a covered benefit under 2 
the terms and conditions of the contract or policy of insurance; 3 
 (b) To a person who is not insured by the health carrier on the 4 
date on which medical or dental care is provided to the person; or 5 
 (c) To an insured who, as a result of his or her failure to pay 6 
the applicable premiums required under the terms and conditions 7 
of a contract or policy of insurance, has no coverage under the 8 
contract or policy on the date on which medical or dental care is 9 
provided to the insured. 10 
 Sec. 17.  1. On or before March 1 of each calendar year, a 11 
health carrier that requires insureds to obtain prior authorization 12 
for medical or dental care shall compile and transmit to the 13 
Commissioner, in a form prescribed by the Commissioner, and 14 
publish on an Internet website maintained by the health carrier in 15 
an easily accessible format the following information for the 16 
immediately preceding plan year, in aggregated form for all 17 
requests for prior authorization received by the health carrier 18 
during the immediately preceding plan year for urgent and non-19 
urgent care and disaggregated in accordance with subsection 2: 20 
 (a) The number of initial requests for prior authorization for 21 
medical or dental care in this State that were approved upon initial 22 
review; 23 
 (b) The number of initial requests for prior authorization for 24 
medical or dental care in this State that resulted in an adverse 25 
determination upon initial review; 26 
 (c) The number of the adverse determinations described in 27 
paragraph (b) that were appealed; 28 
 (d) The number of appeals of adverse determinations described 29 
in paragraph (c) that resulted in a reversal of the adverse 30 
determination; 31 
 (e) The five most common reasons for the adverse 32 
determinations described in paragraph (b); and 33 
 (f) The average time between: 34 
  (1) The submission of an initial request for prior 35 
authorization for medical or dental care in this State and the 36 
response to the request; and 37 
  (2) The submission of an appeal of an adverse 38 
determination on a request for prior authorization for medical or 39 
dental care in this State and the resolution of the appeal. 40 
 2. The information described in subsection 1 must be 41 
disaggregated for the following categories: 42 
 (a) Requests for urgent health care and non-urgent health 43 
care; 44   
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 (b) The specialty of the provider of health care who submitted 1 
a request for prior authorization; and 2 
 (c) The types of medical or dental care at issue in the request 3 
for prior authorization, including the specific types of prescription 4 
drugs, procedures or diagnostic tests involved in the requests. 5 
 3. A health carrier shall not include individually identifiable 6 
health information in the information published pursuant to 7 
subsection 1. 8 
 4. On or before May 1 of each even-numbered year, the 9 
Commissioner shall: 10 
 (a) Compile a report summarizing the information submitted 11 
to the Commissioner pursuant to subsection 1 during the 12 
immediately preceding biennium and providing recommendations 13 
for legislation to improve the process for obtaining prior 14 
authorization; and 15 
 (b) Submit the report and all information provided to the 16 
Commissioner pursuant to subsection 1 to the Director of the 17 
Legislative Counsel Bureau for transmittal to the Joint Interim 18 
Standing Committee on Health and Human Services and the Joint 19 
Interim Standing Committee on Commerce and Labor. 20 
 5. As used in this section, “individually identifiable health 21 
information” means information relating to the provision of 22 
medical or dental care to an insured: 23 
 (a) That specifically identifies the insured; or 24 
 (b) For which there is a reasonable basis to believe that the 25 
information can be used to identify the insured. 26 
 Sec. 18.  (Deleted by amendment.) 27 
 Sec. 19.  NRS 687B.225 is hereby amended to read as follows: 28 
 687B.225 1.  Except as otherwise provided in NRS 29 
689A.0405, 689A.0412, 689A.0413, 689A.0418, 689A.0437, 30 
689A.044, 689A.0445, 689A.0459, 689B.031, 689B.0312, 31 
689B.0313, 689B.0315, 689B.0317, 689B.0319, 689B.0374, 32 
689B.0378, 689C.1665, 689C.1671, 689C.1675, 689C.1676, 33 
695A.1843, 695A.1856, 695A.1865, 695A.1874, 695B.1912, 34 
695B.1913, 695B.1914, 695B.1919, 695B.19197, 695B.1924, 35 
695B.1925, 695B.1942, 695C.1696, 695C.1699, 695C.1713, 36 
695C.1735, 695C.1737, 695C.1743, 695C.1745, 695C.1751, 37 
695G.170, 695G.1705, 695G.171, 695G.1714, 695G.1715, 38 
695G.1719 and 695G.177, and section 15 of this act, any contract 39 
[for group, blanket or individual health] or policy of insurance [or 40 
any contract by a nonprofit hospital, medical or dental service 41 
corporation or organization for dental care] issued by a health 42 
carrier which provides for payment of a certain part of medical or 43 
dental care may require the insured [or member] to obtain prior 44 
authorization for that care from the [insurer or organization. The 45   
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insurer or organization] health carrier in a manner consistent with 1 
this section and sections 2 to 18, inclusive, of this act. 2 
 2. A health carrier that requires an insured to obtain prior 3 
authorization shall: 4 
 (a) File its procedure for obtaining [approval of care] prior 5 
authorization pursuant to this section , including, without 6 
limitation, a list of the items and services for which the health 7 
carrier requires prior authorization and the clinical review criteria 8 
used by the health carrier to evaluate requests for prior 9 
authorization, for approval by the Commissioner . [; and] 10 
 (b) Unless a shorter time period is prescribed by a specific 11 
statute, including, without limitation, NRS 689A.0446, 689B.0361, 12 
689C.1688, 695A.1859, 695B.19087, 695C.16932 and 695G.1703, 13 
[respond to] and except as otherwise provided by paragraph (c), 14 
approve or make an adverse determination on any request for 15 
[approval by the insured or member] prior authorization submitted 16 
by or on behalf of the insured pursuant to this section [within 20 17 
days after it receives the request.] and notify the insured and his or 18 
her provider of health care, or the person designated by the 19 
provider of health care to manage requests for prior authorization, 20 
of the approval or adverse determination: 21 
  (1) For non-urgent medical or dental care, within 7 days 22 
after receiving the request. 23 
  (2) For urgent health care, within 48 hours after receiving 24 
the request. 25 
 (c) If the health carrier requires additional, medically relevant 26 
information or documentation in order to adequately evaluate a 27 
request for prior authorization: 28 
  (1) Notify the insured and the provider of health care who 29 
submitted the request, or the person designated by the provider of 30 
health care to manage requests for prior authorization, within the 31 
applicable amount of time described in paragraph (b) that 32 
additional information is required to evaluate the request; 33 
  (2) Include within the notification sent pursuant to 34 
subparagraph (1) a description, with reasonable specificity, of the 35 
information that the health carrier requires to make a 36 
determination on the request for prior authorization; and 37 
  (3) Approve or make an adverse determination on the 38 
request: 39 
   (I) For non-urgent medical or dental care, within 7 days 40 
after receiving the information. 41 
   (II) For urgent health care, within 48 hours after 42 
receiving the information. 43 
 [2.] 3.  The procedure for prior authorization may not 44 
discriminate among persons licensed to provide the covered care. 45   
 	– 13 – 
 
 
- *AB290_R1* 
 4. A health carrier shall publish its procedures for obtaining 1 
prior authorization, including, without limitation, the clinical 2 
review criteria and the list of items and services for which the 3 
health carrier requires prior authorization and the dates on which 4 
the health carrier began requiring prior authorization in this State 5 
for each item or service, on its Internet website: 6 
 (a) Using clear language that is understandable to an ordinary 7 
layperson, where practicable; and 8 
 (b) In a place that is readily accessible and conspicuous to 9 
insureds and the public. 10 
 5. A health carrier shall not deny a claim based on the failure 11 
of an insured to obtain prior authorization for medical or dental 12 
care if the procedure for obtaining prior authorization established 13 
by the health carrier did not require the insured to obtain prior 14 
authorization for that medical or dental care on the date that the 15 
medical or dental care was provided to the insured. 16 
 6. As used in this section, “clinical review criteria” means 17 
any written screening procedure, decision abstract, clinical 18 
protocol or practice guideline used by the health carrier to 19 
determine the necessity and appropriateness of medical or dental 20 
care. 21 
 Sec. 20.  NRS 695B.320 is hereby amended to read as follows: 22 
 695B.320 1.  Nonprofit hospital and medical or dental service 23 
corporations are subject to the provisions of this chapter, and to the 24 
provisions of chapters 679A and 679B of NRS, subsections 2, 4, 17, 25 
18 and 30 of NRS 680B.010, NRS 680B.025 to 680B.060, 26 
inclusive, chapter 681B of NRS, NRS 686A.010 to 686A.315, 27 
inclusive, 686B.010 to 686B.175, inclusive, 687B.010 to  28 
687B.040, inclusive, 687B.070 to 687B.140, inclusive, 687B.150, 29 
687B.160, 687B.180, 687B.200 to 687B.255, inclusive, and 30 
sections 2 to 18, inclusive, of this act, 687B.270, 687B.310 to 31 
687B.380, inclusive, 687B.410, 687B.420, 687B.430, 687B.500 and 32 
chapters 692B, 692C, 693A and 696B of NRS, to the extent 33 
applicable and not in conflict with the express provisions of this 34 
chapter. 35 
 2. For the purposes of this section and the provisions set forth 36 
in subsection 1, a nonprofit hospital and medical or dental service 37 
corporation is included in the meaning of the term “insurer.” 38 
 Sec. 21.  NRS 232.320 is hereby amended to read as follows: 39 
 232.320 1.  The Director: 40 
 (a) Shall appoint, with the consent of the Governor, 41 
administrators of the divisions of the Department, who are 42 
respectively designated as follows: 43 
  (1) The Administrator of the Aging and Disability Services 44 
Division; 45   
 	– 14 – 
 
 
- *AB290_R1* 
  (2) The Administrator of the Division of Welfare and 1 
Supportive Services; 2 
  (3) The Administrator of the Division of Child and Family 3 
Services; 4 
  (4) The Administrator of the Division of Health Care 5 
Financing and Policy; and 6 
  (5) The Administrator of the Division of Public and 7 
Behavioral Health. 8 
 (b) Shall administer, through the divisions of the Department, 9 
the provisions of chapters 63, 424, 425, 427A, 432A to 442, 10 
inclusive, 446 to 450, inclusive, 458A and 656A of NRS, NRS 11 
127.220 to 127.310, inclusive, 422.001 to 422.410, inclusive, and 12 
sections 25 to 41, inclusive, of this act, 422.580, 432.010 to 13 
432.133, inclusive, 432B.6201 to 432B.626, inclusive, 444.002 to 14 
444.430, inclusive, and 445A.010 to 445A.055, inclusive, and all 15 
other provisions of law relating to the functions of the divisions of 16 
the Department, but is not responsible for the clinical activities of 17 
the Division of Public and Behavioral Health or the professional line 18 
activities of the other divisions. 19 
 (c) Shall administer any state program for persons with 20 
developmental disabilities established pursuant to the 21 
Developmental Disabilities Assistance and Bill of Rights Act of 22 
2000, 42 U.S.C. §§ 15001 et seq. 23 
 (d) Shall, after considering advice from agencies of local 24 
governments and nonprofit organizations which provide social 25 
services, adopt a master plan for the provision of human services in 26 
this State. The Director shall revise the plan biennially and deliver a 27 
copy of the plan to the Governor and the Legislature at the 28 
beginning of each regular session. The plan must: 29 
  (1) Identify and assess the plans and programs of the 30 
Department for the provision of human services, and any 31 
duplication of those services by federal, state and local agencies; 32 
  (2) Set forth priorities for the provision of those services; 33 
  (3) Provide for communication and the coordination of those 34 
services among nonprofit organizations, agencies of local 35 
government, the State and the Federal Government; 36 
  (4) Identify the sources of funding for services provided by 37 
the Department and the allocation of that funding; 38 
  (5) Set forth sufficient information to assist the Department 39 
in providing those services and in the planning and budgeting for the 40 
future provision of those services; and 41 
  (6) Contain any other information necessary for the 42 
Department to communicate effectively with the Federal 43 
Government concerning demographic trends, formulas for the 44   
 	– 15 – 
 
 
- *AB290_R1* 
distribution of federal money and any need for the modification of 1 
programs administered by the Department. 2 
 (e) May, by regulation, require nonprofit organizations and state 3 
and local governmental agencies to provide information regarding 4 
the programs of those organizations and agencies, excluding 5 
detailed information relating to their budgets and payrolls, which the 6 
Director deems necessary for the performance of the duties imposed 7 
upon him or her pursuant to this section. 8 
 (f) Has such other powers and duties as are provided by law. 9 
 2.  Notwithstanding any other provision of law, the Director, or 10 
the Director’s designee, is responsible for appointing and removing 11 
subordinate officers and employees of the Department. 12 
 Sec. 22.  NRS 287.010 is hereby amended to read as follows: 13 
 287.010 1.  The governing body of any county, school 14 
district, municipal corporation, political subdivision, public 15 
corporation or other local governmental agency of the State of 16 
Nevada may: 17 
 (a) Adopt and carry into effect a system of group life, accident 18 
or health insurance, or any combination thereof, for the benefit of its 19 
officers and employees, and the dependents of officers and 20 
employees who elect to accept the insurance and who, where 21 
necessary, have authorized the governing body to make deductions 22 
from their compensation for the payment of premiums on the 23 
insurance. 24 
 (b) Purchase group policies of life, accident or health insurance, 25 
or any combination thereof, for the benefit of such officers and 26 
employees, and the dependents of such officers and employees, as 27 
have authorized the purchase, from insurance companies authorized 28 
to transact the business of such insurance in the State of Nevada, 29 
and, where necessary, deduct from the compensation of officers and 30 
employees the premiums upon insurance and pay the deductions 31 
upon the premiums. 32 
 (c) Provide group life, accident or health coverage through a 33 
self-insurance reserve fund and, where necessary, deduct 34 
contributions to the maintenance of the fund from the compensation 35 
of officers and employees and pay the deductions into the fund. The 36 
money accumulated for this purpose through deductions from the 37 
compensation of officers and employees and contributions of the 38 
governing body must be maintained as an internal service fund as 39 
defined by NRS 354.543. The money must be deposited in a state or 40 
national bank or credit union authorized to transact business in the 41 
State of Nevada. Any independent administrator of a fund created 42 
under this section is subject to the licensing requirements of chapter 43 
683A of NRS, and must be a resident of this State. Any contract 44 
with an independent administrator must be approved by the 45   
 	– 16 – 
 
 
- *AB290_R1* 
Commissioner of Insurance as to the reasonableness of 1 
administrative charges in relation to contributions collected and 2 
benefits provided. The provisions of NRS 439.581 to 439.597, 3 
inclusive, 686A.135, paragraphs (b) and (c) of subsection 2 and 4 
subsections 1, 3, 4 and 5 of NRS 687B.225, 687B.352, 687B.408, 5 
687B.692, [687B.723,] 687B.725, 687B.805, 689B.030 to 6 
689B.0317, inclusive, paragraphs (b) and (c) of subsection 1 of NRS 7 
689B.0319, subsections 2, 4, 6 and 7 of NRS 689B.0319, 689B.033 8 
to 689B.0369, inclusive, 689B.0375 to 689B.050, inclusive, 9 
689B.0675, 689B.265, 689B.287 and 689B.500 and sections 2 to 10 
18, inclusive, of this act apply to coverage provided pursuant to this 11 
paragraph, except that the provisions of NRS 689B.0378, 12 
689B.03785 and 689B.500 only apply to coverage for active officers 13 
and employees of the governing body, or the dependents of such 14 
officers and employees. 15 
 (d) Defray part or all of the cost of maintenance of a self-16 
insurance fund or of the premiums upon insurance. The money for 17 
contributions must be budgeted for in accordance with the laws 18 
governing the county, school district, municipal corporation, 19 
political subdivision, public corporation or other local governmental 20 
agency of the State of Nevada. 21 
 2.  If a school district offers group insurance to its officers and 22 
employees pursuant to this section, members of the board of trustees 23 
of the school district must not be excluded from participating in the 24 
group insurance. If the amount of the deductions from compensation 25 
required to pay for the group insurance exceeds the compensation to 26 
which a trustee is entitled, the difference must be paid by the trustee. 27 
 3.  In any county in which a legal services organization exists, 28 
the governing body of the county, or of any school district, 29 
municipal corporation, political subdivision, public corporation or 30 
other local governmental agency of the State of Nevada in the 31 
county, may enter into a contract with the legal services 32 
organization pursuant to which the officers and employees of the 33 
legal services organization, and the dependents of those officers and 34 
employees, are eligible for any life, accident or health insurance 35 
provided pursuant to this section to the officers and employees, and 36 
the dependents of the officers and employees, of the county, school 37 
district, municipal corporation, political subdivision, public 38 
corporation or other local governmental agency. 39 
 4.  If a contract is entered into pursuant to subsection 3, the 40 
officers and employees of the legal services organization: 41 
 (a) Shall be deemed, solely for the purposes of this section, to be 42 
officers and employees of the county, school district, municipal 43 
corporation, political subdivision, public corporation or other local 44   
 	– 17 – 
 
 
- *AB290_R1* 
governmental agency with which the legal services organization has 1 
contracted; and 2 
 (b) Must be required by the contract to pay the premiums or 3 
contributions for all insurance which they elect to accept or of which 4 
they authorize the purchase. 5 
 5.  A contract that is entered into pursuant to subsection 3: 6 
 (a) Must be submitted to the Commissioner of Insurance for 7 
approval not less than 30 days before the date on which the contract 8 
is to become effective. 9 
 (b) Does not become effective unless approved by the 10 
Commissioner. 11 
 (c) Shall be deemed to be approved if not disapproved by the 12 
Commissioner within 30 days after its submission. 13 
 6.  As used in this section, “legal services organization” means 14 
an organization that operates a program for legal aid and receives 15 
money pursuant to NRS 19.031. 16 
 Sec. 23.  NRS 287.04335 is hereby amended to read as 17 
follows: 18 
 287.04335 If the Board provides health insurance through a 19 
plan of self-insurance, it shall comply with the provisions of  20 
NRS 439.581 to 439.597, inclusive, 686A.135, paragraphs (b) and 21 
(c) of subsection 2 and subsections 1, 3, 4 and 5 of NRS 687B.225, 22 
687B.352, 687B.409, 687B.692, [687B.723,] 687B.725, 687B.805, 23 
689B.0353, 689B.255, 695C.1723, 695G.150, 695G.155, 695G.160, 24 
695G.162, 695G.1635, 695G.164, 695G.1645, 695G.1665, 25 
695G.167, 695G.1675, 695G.170 to 695G.1712, inclusive, 26 
695G.1714 to 695G.174, inclusive, 695G.176, 695G.177, 695G.200 27 
to 695G.230, inclusive, 695G.241 to 695G.310, inclusive, 695G.405 28 
and 695G.415, and sections 2 to 18, inclusive, of this act in the 29 
same manner as an insurer that is licensed pursuant to title 57 of 30 
NRS is required to comply with those provisions. 31 
 Sec. 24.  Chapter 422 of NRS is hereby amended by adding 32 
thereto the provisions set forth as sections 25 to 41, inclusive, of this 33 
act. 34 
 Sec. 25.  (Deleted by amendment.) 35 
 Sec. 26.  As used in sections 26 to 41, inclusive, of this act, 36 
unless the context otherwise requires, the words and terms defined 37 
in sections 27 to 33, inclusive, of this act have the meanings 38 
ascribed to them in those sections. 39 
 Sec. 27.  “Adverse determination” means a determination by 40 
the Department or a Medicaid managed care entity that an 41 
admission or other medical care or dental care that is a covered 42 
benefit has been reviewed and, based upon the information 43 
provided, does not meet the relevant requirements for medical 44 
necessity, appropriateness, health care setting, level of care or 45   
 	– 18 – 
 
 
- *AB290_R1* 
effectiveness, and the requested care or service or payment for the 1 
care or service is therefore denied.  2 
 Sec. 28.  (Deleted by amendment.) 3 
 Sec. 29.  “Individually identifiable health information” 4 
means information relating to the provision of health care to a 5 
recipient: 6 
 1. That specifically identifies the recipient; or 7 
 2. For which there is a reasonable basis to believe that the 8 
information can be used to identify the recipient. 9 
 Sec. 29.5.  “Medicaid managed care entity” means: 10 
 1. A health maintenance organization or other managed care 11 
organization that enters into a contract with the Department or the 12 
Division pursuant to NRS 422.273 to provide health care services 13 
to recipients of Medicaid under the State Plan for Medicaid or the 14 
Children’s Health Insurance Program; or 15 
 2. A utilization review organization, as defined in NRS 16 
695G.085, that conducts utilization reviews for the Department or 17 
a health maintenance organization or managed care organization 18 
described in subsection 1 with respect to Medicaid or the 19 
Children’s Health Insurance Program.  20 
 Sec. 30.  1. Except as otherwise provided in subsection 2 or 21 
where otherwise required by federal law, “medically necessary” 22 
has the meaning ascribed to it in NRS 695G.055. 23 
 2. If federal law or regulations define “medically necessary” 24 
for purposes related to Medicaid or the Children’s Health 25 
Insurance Program differently from the manner in which that 26 
term is defined in subsection 1, the Department may, by 27 
regulation, adopt the definition established by federal law or 28 
regulations. Any such definition supersedes the definition 29 
established in subsection 1. 30 
 Sec. 31.  “Provider of health care” means a person who 31 
participates in the State Plan for Medicaid or the Children’s 32 
Health Insurance Program as a provider of items or services. 33 
 Sec. 32.  “Recipient” means a natural person who receives 34 
benefits through Medicaid or the Children’s Health Insurance 35 
Program, as applicable. 36 
 Sec. 33.  (Deleted by amendment.) 37 
 Sec. 34.  1. The Department, with respect to Medicaid and 38 
the Children’s Health Insurance Program, shall establish written 39 
procedures for obtaining prior authorization for medical or dental 40 
care which: 41 
 (a) Apply to the delivery of medical or dental care to recipients 42 
of Medicaid or the Children’s Health Insurance Program: 43 
  (1) Directly by the Department; and 44   
 	– 19 – 
 
 
- *AB290_R1* 
  (2) Through managed care in accordance with NRS 1 
422.273; and 2 
 (b) Must include, without limitation: 3 
 (1) A list of the items and services for which the Department 4 
requires prior authorization; and 5 
 (2) A description of the clinical review criteria used by the 6 
Department. 7 
 2. The Department and each Medicaid managed care entity 8 
shall publish the written procedures for obtaining prior 9 
authorization established by the Department pursuant to 10 
subsection 1, including, without limitation, the clinical review 11 
criteria, on an Internet website maintained by the Department or 12 
the Medicaid managed care entity, as applicable: 13 
 (a) Using clear language that is understandable to an ordinary 14 
layperson, where practicable; and 15 
 (b) In a place that is readily accessible and conspicuous to 16 
recipients and the public. 17 
 3. If the Department amends the procedure for obtaining 18 
prior authorization adopted pursuant to subsection 1, including, 19 
without limitation, changing the items and services for which the 20 
Department requires prior authorization or changing the clinical 21 
review criteria used by the Department, the Department and each 22 
Medicaid managed care entity shall update the information 23 
published on its Internet website pursuant to subsection 2 to 24 
reflect the amended procedure for obtaining prior authorization 25 
and the date on which the amended procedure takes effect. 26 
 4. A change to the Department’s procedure for obtaining 27 
prior authorization may not take effect until the date on which the 28 
Department updated the information published on its Internet 29 
website pursuant to subsection 3. 30 
 5. The Department or a Medicaid managed care entity shall 31 
not deny a claim based on the failure of a recipient to obtain prior 32 
authorization for medical or dental care if the procedure for 33 
obtaining prior authorization established by the Department 34 
pursuant to this section did not require the recipient to obtain 35 
prior authorization for that medical or dental care on the date that 36 
the medical or dental care was provided to the recipient. 37 
 6. As used in this section, “clinical review criteria” means 38 
any written screening procedure, decision abstract, clinical 39 
protocol or practice guideline used by the Department to 40 
determine the necessity and appropriateness of medical or dental 41 
care. 42 
 Sec. 35.  1. Unless a shorter time period is prescribed by a 43 
specific statute, and except as otherwise provided in subsections 2 44 
and 3, the Department or a Medicaid managed care entity, with 45   
 	– 20 – 
 
 
- *AB290_R1* 
respect to Medicaid and the Children’s Health Insurance 1 
Program, shall approve or make an adverse determination on a 2 
request for prior authorization submitted by or on behalf of a 3 
recipient and notify the recipient and his or her provider of health 4 
care, or the person designated by the provider of health care to 5 
manage requests for prior authorization, of the approval or 6 
adverse determination within 7 days after receiving the request. 7 
 2. If the Department or Medicaid managed care entity 8 
requires additional, medically relevant information or 9 
documentation in order to adequately evaluate a request for prior 10 
authorization, the Department or Medicaid managed care entity, 11 
as applicable, shall: 12 
 (a) Notify the recipient and the provider of health care who 13 
submitted the request, or the person designated by the provider of 14 
health care to manage requests for prior authorization, within 7 15 
days after receiving the request that additional information is 16 
required to evaluate the request; 17 
 (b) Include within the notification sent pursuant to paragraph 18 
(a) a description, with reasonable specificity, of the information 19 
that the Department or Medicaid managed care entity, as 20 
applicable, requires to make a determination on the request for 21 
prior authorization; and 22 
 (c) Approve or make an adverse determination on the request 23 
within 7 days after receiving the information. 24 
 3. The provisions of this section do not apply to requests for 25 
prior authorization for prescription drugs, for personal care 26 
services or for services which are provided under Medicaid 27 
pursuant to 42 U.S.C. § 1396n(i) or a waiver granted pursuant to 28 
42 U.S.C. § 1396n(c) by the Secretary of Health and Human 29 
Services. 30 
 Sec. 36.  1. The Department or a Medicaid managed care 31 
entity, with respect to Medicaid and the Children’s Health 32 
Insurance Program, shall not make an adverse determination on a 33 
request for prior authorization unless the adverse determination is 34 
made by a physician, a pharmacist or, for a request relating to 35 
dental care, a dentist, who: 36 
 (a) Holds an unrestricted license to practice medicine, 37 
pharmacy or dentistry, as applicable, in any state or territory of 38 
the United States; and 39 
 (b) Is acting within the scope of his or her practice with respect 40 
to evaluating the particular medical or dental care involved in the 41 
request and, to the extent practicable, is of the same or similar 42 
specialty as a physician, pharmacist or dentist, as applicable, who 43 
typically manages or treats the medical or dental condition or 44 
provides the medical or dental care involved in the request.  45   
 	– 21 – 
 
 
- *AB290_R1* 
 2. Upon rendering an adverse determination on a request for 1 
prior authorization, the Department or a Medicaid managed care 2 
entity, as applicable, shall immediately transmit to the recipient to 3 
whom the request pertains a written notice that contains: 4 
 (a) A specific description of all reasons that the Department or 5 
Medicaid managed care entity, as applicable, made the adverse 6 
determination; 7 
 (b) A description of any documentation that the Department or 8 
Medicaid managed care entity, as applicable, requested from the 9 
recipient or a provider of health care of the recipient and did not 10 
receive or deemed insufficient, if the failure to receive sufficient 11 
documentation contributed to the adverse determination; 12 
 (c) A statement that the recipient has the right to appeal the 13 
adverse determination; 14 
 (d) Instructions, written in clear language that is 15 
understandable to an ordinary layperson, describing how the 16 
recipient can appeal the adverse determination through the 17 
process for appeals established pursuant to subsection 3; and 18 
 (e) A description of any documentation that may be necessary 19 
or pertinent to a potential appeal. 20 
 3.  The Department shall establish a process that allows a 21 
recipient to appeal an adverse determination on a request for prior 22 
authorization. The Department may elect to utilize the procedures 23 
for hearings established for appeals of denials of claims of 24 
benefits under Medicaid pursuant to NRS 422.275 to 422.280, 25 
inclusive, to satisfy that requirement. If the Department utilizes 26 
such procedures for that purpose, the Department shall, upon the 27 
request of a hearing officer, make available to the hearing officer 28 
a licensed medical professional, which may include the Medical 29 
Director for Medicaid, as available, to provide clinical input and 30 
expertise which may be necessary to evaluate the appeal of an 31 
adverse determination. 32 
 4. Notwithstanding the provisions of subsection 3, a Medicaid 33 
managed care entity may establish a separate process that allows a 34 
recipient to appeal an adverse determination on a request for prior 35 
authorization. If the Medicaid managed care entity does not 36 
reverse the adverse determination after the exhaustion of that 37 
process, the recipient my appeal to the Department pursuant to 38 
subsection 3. 39 
 Sec. 37.  1. If the Department or a Medicaid managed care 40 
entity approves a request for prior authorization, the approval 41 
remains valid until 12 months after the date on which the request 42 
is approved or, if federal law establishes a different amount of 43 
time for which a request for prior authorization is required to 44 
remain valid, the amount of time established by the federal law. 45   
 	– 22 – 
 
 
- *AB290_R1* 
 2. The Department or a Medicaid managed care entity shall 1 
not revoke or impose an additional limit, condition or restriction 2 
on a request for prior authorization that the Department or 3 
Medicaid managed care entity, as applicable, has previously 4 
approved unless: 5 
 (a) The care at issue in the request was not provided to the 6 
recipient within 90 business days after the Department or 7 
Medicaid managed care entity, as applicable, received the request; 8 
 (b) The Department or Medicaid managed care entity, as 9 
applicable, determines that a recipient or a provider of health care 10 
procured the approval by fraud or material misrepresentation; or 11 
 (c) The Department or Medicaid managed care entity, as 12 
applicable, determines that the care at issue in the request was not 13 
covered by Medicaid or the Children’s Health Insurance Program, 14 
as applicable, at the time the care was provided. 15 
 3. If the Department or a Medicaid managed care entity has 16 
approved a request for prior authorization, the Department or 17 
Medicaid managed care entity, as applicable, shall not deny or 18 
refuse to promptly pay a clean claim for the approved medical  19 
or dental care unless: 20 
 (a) The claim is not timely submitted;  21 
 (b) The claim is not submitted in accordance with the 22 
requirements of the Department or the Federal Government; or 23 
 (c) The Department or Medicaid managed care entity, as 24 
applicable, determines that the recipient or provider of health care 25 
procured the prior authorization by fraud or material 26 
misrepresentation.  27 
 4. If the Department or a Medicaid managed care entity does 28 
not deny a clean claim for approved medical or dental care 29 
pursuant to subsection 3, the Department or Medicaid managed 30 
care entity, as applicable, shall pay the claim at the same rate that 31 
the Department or Medicaid managed care entity, as applicable, is 32 
contractually obligated to or would ordinarily pay a provider of 33 
health care for providing the specific type of care that was 34 
approved and provided to the recipient. 35 
 5. As used in this section, “clean claim” has the meaning 36 
ascribed to it in 42 C.F.R. § 447.45. 37 
 Sec. 38.  1.  The Department or a Medicaid managed care 38 
entity, with respect to Medicaid and the Children’s Health 39 
Insurance Program, shall not require prior authorization for 40 
covered emergency services, including, where applicable, 41 
transportation by ambulance to a hospital or other medical 42 
facility. 43 
 2. If the Department or a Medicaid managed care entity 44 
requires a recipient or his or her provider of health care to notify 45   
 	– 23 – 
 
 
- *AB290_R1* 
the Department or Medicaid managed care entity, as applicable, 1 
that the recipient has been admitted to a hospital to receive 2 
emergency services or has received emergency services, the 3 
Department or Medicaid managed care entity, as applicable, shall 4 
not require a recipient or a provider of health care to transmit 5 
such a notice earlier than the end of the business day immediately 6 
following the day after the date on which the recipient was 7 
admitted or the emergency services were provided, as applicable. 8 
 3. The Department or a Medicaid managed care entity shall 9 
not deny coverage for emergency services covered by Medicaid or 10 
the Children’s Health Insurance Program that are medically 11 
necessary. Emergency services are presumed to be medically 12 
necessary if, within 72 hours after a recipient is admitted to 13 
receive emergency services, the recipient’s provider of health care 14 
transmits to the Department or Medicaid managed care entity, as 15 
applicable, a certification, in writing, that the condition of the 16 
recipient required emergency services. The Department or 17 
Medicaid managed care entity may rebut that presumption by 18 
establishing, by clear and convincing evidence, that the emergency 19 
services were not medically necessary. 20 
 4. As used in this section, “emergency services” means health 21 
care services that are provided by a provider of health care to 22 
screen and to stabilize a recipient after the sudden onset of a 23 
medical condition that manifests itself by symptoms of such 24 
sufficient severity that a prudent person would believe that the 25 
absence of immediate medical attention could result in: 26 
 (a) Serious jeopardy to the health of the recipient; 27 
 (b) Serious jeopardy to the health of a fetus of the recipient; 28 
 (c) Serious impairment of a bodily function of the recipient; or 29 
 (d) Serious dysfunction of any bodily organ or part of the 30 
recipient. 31 
 Sec. 39. Nothing in sections 34 to 38, inclusive, of this act 32 
shall be construed to require the Department or a Medicaid 33 
managed care entity to provide coverage: 34 
 1.  For medical or dental care that, regardless of whether such 35 
care is medically necessary, would not be a covered benefit under 36 
the terms and conditions of Medicaid or the Children’s Health 37 
Insurance Program, as applicable; or 38 
 2.  To a person who is not a recipient or is not otherwise 39 
eligible to receive coverage under Medicaid or the Children’s 40 
Health Insurance Program, as applicable, on the date on which 41 
medical or dental care is provided to the person. 42 
 Sec. 40.  1. On or before March 1 of each calendar year, the 43 
Department and each Medicaid managed care entity shall publish 44 
on an Internet website maintained by the Department or Medicaid 45   
 	– 24 – 
 
 
- *AB290_R1* 
managed care entity, as applicable, in an easily accessible format 1 
the following information for the immediately preceding calendar 2 
year, in aggregated form for all requests for prior authorization 3 
received by the Department or Medicaid managed care entity, as 4 
applicable, during the immediately preceding year and 5 
disaggregated in accordance with subsection 2: 6 
 (a) The number of initial requests for prior authorization for 7 
medical or dental care that were approved upon initial review; 8 
 (b) The number of initial requests for prior authorization for 9 
medical or dental care that resulted in an adverse determination 10 
upon initial review; 11 
 (c) The number of the adverse determinations described in 12 
paragraph (b) that were appealed; 13 
 (d) The number of appeals of adverse determinations described 14 
in paragraph (c) that resulted in a reversal of the adverse 15 
determination; 16 
 (e) The five most common reasons for the adverse 17 
determinations described in paragraph (b); and 18 
 (f) The average time between: 19 
  (1) The submission of an initial request for prior 20 
authorization for medical or dental care in this State and the 21 
response to the request; and 22 
  (2) The submission of an appeal of an adverse 23 
determination on a request for prior authorization for medical or 24 
dental care and the resolution of the appeal. 25 
 2. The information described in subsection 1 must be 26 
disaggregated for the following categories: 27 
 (a) The specialty of the provider of health care who submitted 28 
a request for prior authorization; and 29 
 (b) The types of medical or dental care at issue in the request 30 
for prior authorization, including the specific types of prescription 31 
drugs, procedures or diagnostic tests involved in the requests. 32 
 3. The Department or a Medicaid managed care entity shall 33 
not include individually identifiable health information in the 34 
information published pursuant to subsection 1. 35 
 Sec. 41.  1. On or before March 1 of each calendar year, the 36 
Department and each Medicaid managed care entity shall: 37 
 (a) Compile a report containing the following information for 38 
Medicaid and the Children’s Health Insurance Program: 39 
  (1) The items and services for which the Department or 40 
Medicaid managed care entity requires prior authorization and, 41 
for each item or service: 42 
   (I) The date on which the Department or Medicaid 43 
managed care entity began requiring prior authorization for that 44 
item or service;  45   
 	– 25 – 
 
 
- *AB290_R1* 
   (II) The number of requests for prior authorization 1 
received by the Department or Medicaid managed care entity 2 
during the immediately preceding calendar year for the provision 3 
of the item or service; 4 
   (III) The number and percentage of the requests listed 5 
pursuant to sub-subparagraph (II) that were approved; 6 
   (IV) The number and percentage of the requests listed 7 
pursuant to sub-subparagraph (II) that resulted in adverse 8 
determinations; and 9 
   (V) The number of appeals from adverse determinations 10 
during the immediately preceding calendar year and the 11 
percentage of those appeals that were reversed on appeal by the 12 
Department or Medicaid managed care entity; 13 
  (2) For all requests for prior authorization received by the 14 
Department or Medicaid managed care entity during the 15 
immediately preceding calendar year, the average and median 16 
time between: 17 
   (I) The Department or Medicaid managed care entity 18 
receiving a request for prior authorization and the Department or 19 
Medicaid managed care entity approving or making an adverse 20 
determination on the request; and 21 
   (II) The submission of an appeal of an adverse 22 
determination on a request for prior authorization and the 23 
resolution of the appeal;  24 
 (b) Post the report on the Internet website maintained by the 25 
Department or Medicaid managed care entity; and 26 
 (c) Submit the report to the Director of the Legislative Counsel 27 
Bureau for transmittal to the Joint Interim Standing Committee 28 
on Health and Human Services. 29 
 2. The Department or a Medicaid managed care entity shall 30 
not include individually identifiable health information in a report 31 
published pursuant to subsection 1. 32 
 Sec. 42.  NRS 422.403 is hereby amended to read as follows: 33 
 422.403 1.  The Department shall, by regulation, establish and 34 
manage the use by the Medicaid program of step therapy and prior 35 
authorization for prescription drugs. 36 
 2.  The Drug Use Review Board shall: 37 
 (a) Advise the Department concerning the use by the Medicaid 38 
program of step therapy and prior authorization for prescription 39 
drugs; 40 
 (b) Develop step therapy protocols and prior authorization 41 
policies and procedures that comply with the provisions of sections 42 
26 to 41, inclusive, of this act for use by the Medicaid program for 43 
prescription drugs; and 44   
 	– 26 – 
 
 
- *AB290_R1* 
 (c) Review and approve, based on clinical evidence and best 1 
clinical practice guidelines and without consideration of the cost of 2 
the prescription drugs being considered, step therapy protocols used 3 
by the Medicaid program for prescription drugs. 4 
 3.  The step therapy protocol established pursuant to this section 5 
must not apply to a drug approved by the Food and Drug 6 
Administration that is prescribed to treat a psychiatric condition of a 7 
recipient of Medicaid, if: 8 
 (a) The drug has been approved by the Food and Drug 9 
Administration with indications for the psychiatric condition of the 10 
insured or the use of the drug to treat that psychiatric condition is 11 
otherwise supported by medical or scientific evidence;  12 
 (b) The drug is prescribed by: 13 
  (1) A psychiatrist; 14 
  (2) A physician assistant under the supervision of a 15 
psychiatrist;  16 
  (3) An advanced practice registered nurse who has the 17 
psychiatric training and experience prescribed by the State Board of 18 
Nursing pursuant to NRS 632.120; or 19 
  (4) A primary care provider that is providing care to an 20 
insured in consultation with a practitioner listed in subparagraph (1), 21 
(2) or (3), if the closest practitioner listed in subparagraph (1), (2) or 22 
(3) who participates in Medicaid is located 60 miles or more from 23 
the residence of the recipient; and 24 
 (c) The practitioner listed in paragraph (b) who prescribed the 25 
drug knows, based on the medical history of the recipient, or 26 
reasonably expects each alternative drug that is required to be used 27 
earlier in the step therapy protocol to be ineffective at treating the 28 
psychiatric condition.  29 
 4. The Department shall not require the Drug Use Review 30 
Board to develop, review or approve prior authorization policies or 31 
procedures necessary for the operation of the list of preferred 32 
prescription drugs developed pursuant to NRS 422.4025. 33 
 5.  The Department shall accept recommendations from the 34 
Drug Use Review Board as the basis for developing or revising step 35 
therapy protocols and prior authorization policies and procedures 36 
used by the Medicaid program for prescription drugs. 37 
 6. As used in this section: 38 
 (a) “Medical or scientific evidence” has the meaning ascribed to 39 
it in NRS 695G.053. 40 
 (b) “Step therapy protocol” means a procedure that requires a 41 
recipient of Medicaid to use a prescription drug or sequence of 42 
prescription drugs other than a drug that a practitioner recommends 43 
for treatment of a psychiatric condition of the recipient before 44 
Medicaid provides coverage for the recommended drug. 45   
 	– 27 – 
 
 
- *AB290_R1* 
 Sec. 43.  (Deleted by amendment.) 1 
 Sec. 44.  NRS 608.1555 is hereby amended to read as follows: 2 
 608.1555 Any employer who provides benefits for health care 3 
to his or her employees shall provide the same benefits and pay 4 
providers of health care in the same manner as a policy of insurance 5 
pursuant to chapters 689A and 689B of NRS, including, without 6 
limitation, as required by paragraphs (b) and (c) of subsection 2 7 
and subsections 1, 3, 4 and 5 of NRS 687B.225, NRS 687B.409 [, 8 
687B.723] and 687B.725 [.] and sections 2 to 18, inclusive, of this 9 
act. 10 
 Sec. 45.  1.  The amendatory provisions of this act do not 11 
apply to a request for prior authorization submitted: 12 
 (a) Under a contract or policy of health insurance issued before 13 
January 1, 2026, but apply to any request for prior authorization 14 
submitted under any renewal of such a contract or policy. 15 
 (b) To the Department of Health and Human Services or a 16 
Medicaid managed care entity, as defined in section 29.5 of this act, 17 
before January 1, 2026, for medical or dental care provided to a 18 
recipient of Medicaid or insurance under the Children’s Health 19 
Insurance Program. 20 
 2. A health carrier must, in order to continue requiring prior 21 
authorization in contracts or policies of health insurance issued or 22 
renewed after January 1, 2026: 23 
 (a) Develop a procedure for obtaining prior authorization that 24 
complies with NRS 687B.225, as amended by section 19 of this act, 25 
and sections 2 to 18, inclusive, of this act; and 26 
 (b) Obtain the approval of the Commissioner of Insurance 27 
pursuant to NRS 687B.225, as amended by section 19 of this act, for 28 
the procedure developed pursuant to paragraph (a). 29 
 3. As used in this section, “health carrier” has the meaning 30 
ascribed to it in section 5 of this act. 31 
 Sec. 46.  The provisions of NRS 218D.380 do not apply to any 32 
provision of this act which adds or revises a requirement to submit a 33 
report to the Legislature. 34 
 Sec. 47.  The provisions of NRS 354.599 do not apply to any 35 
additional expenses of a local government that are related to the 36 
provisions of this act. 37 
 Sec. 47.5.  NRS 687B.723 and 695D.2153 are hereby repealed. 38 
 Sec. 48.  1. This section and section 45 of this act become 39 
effective upon passage and approval. 40 
 2. Sections 1 to 44, inclusive, 46, 47 and 47.5 of this act 41 
become effective: 42 
 (a) Upon passage and approval for the purpose of adopting any 43 
regulations, performing any other preparatory administrative tasks 44 
that are necessary to carry out the provisions of this act and 45   
 	– 28 – 
 
 
- *AB290_R1* 
approving procedures for obtaining prior authorization pursuant to 1 
NRS 687B.225, as amended by section 19 of this act, and section 45 2 
of this act; and 3 
 (b) On January 1, 2026, for all other purposes. 4 
 
 
TEXT OF REPEALED SECTION S 
 
 
 687B.723 Claim for dental care: Health carrier or 
administrator of health benefit plan prohibited from denying 
claim for which prior authorization has been granted; 
exceptions. 
 1. A health carrier which provides dental coverage or an 
administrator of a health benefit plan that includes dental coverage 
shall not refuse to pay a claim for dental care for which the health 
carrier or administrator, as applicable, has granted prior 
authorization unless: 
 (a) A limitation on coverage provided under the applicable 
health benefit plan, including, without limitation, a limitation on 
total costs or frequency of services: 
  (1) Did not apply at the time the prior authorization was 
granted; and 
  (2) Applied at the time of the provision of the dental care for 
which the prior authorization was granted because additional 
covered dental care was provided to the insured after the prior 
authorization was granted and before the provision of the dental care 
for which prior authorization was granted; 
 (b) The documentation provided by the person submitting the 
claim clearly fails to support the claim for which prior authorization 
was originally granted; 
 (c) After the prior authorization was granted, additional dental 
care was provided to the insured or the condition of the insured 
otherwise changed such that: 
  (1) The dental care for which prior authorization was granted 
is no longer medically necessary; or 
  (2) The health carrier or administrator, as applicable, would 
be required to deny prior authorization under the terms and 
conditions of the applicable health benefit plan that were in effect at 
the time of the provision of the dental care for which prior 
authorization was granted; 
 (d) Another person or entity is responsible for the payment; 
 (e) The dentist has previously been paid for the procedures 
covered by the claim;   
 	– 29 – 
 
 
- *AB290_R1* 
 (f) The claim was fraudulent or the prior authorization was 
based, in whole or in part, on materially false information provided 
by the dentist or insured or another person who is not affiliated with 
the health carrier or administrator, as applicable; or 
 (g) The insured was not eligible to receive the dental care for 
which the claim was made on the date that the dental care was 
provided.  
 2. Any provision of a contract that conflicts with this section is 
against public policy, void and unenforceable. 
 3. As used in this section: 
 (a) “Medically necessary” means dental care that a prudent 
dentist would provide to a patient to prevent, diagnose or treat an 
illness, injury or disease, or any symptoms thereof, that is necessary 
and: 
  (1) Provided in accordance with generally accepted standards 
of dental practice; 
  (2) Clinically appropriate with regard to type, frequency, 
extent, location and duration; 
  (3) Not primarily provided for the convenience of the patient 
or dentist; 
  (4) Required to improve a specific dental condition of a 
patient or to preserve the existing state of oral health of the patient; 
and 
  (5) The most clinically appropriate level of dental care that 
may be safely provided to the patient. 
 (b) “Prior authorization” means any communication issued by a 
health carrier which provides dental coverage or an administrator of 
a health benefit plan that includes dental coverage in response to a 
request by a dentist in the form prescribed by the health carrier or 
administrator, as applicable, which indicates that specific dental care 
provided to an insured is: 
  (1) Covered under the health benefit plan issued to the 
insured; and 
  (2) Reimbursable in a specific amount, subject to applicable 
deductibles, copayments and coinsurance. 
 695D.2153 Claims: Organization for dental care or 
administrator prohibited from denying claim for which prior 
authorization has been granted; exceptions. 
 1. An organization for dental care or an administrator of a 
dental plan shall not refuse to pay a claim for dental care for which 
the organization for dental care or administrator, as applicable, has 
granted prior authorization unless: 
 (a) A limitation on coverage provided under the applicable plan 
for dental care, including, without limitation, a limitation on total 
costs or frequency of services:   
 	– 30 – 
 
 
- *AB290_R1* 
  (1) Did not apply at the time the prior authorization was 
granted; and 
  (2) Applied at the time of the provision of the dental care for 
which the prior authorization was granted because additional 
covered dental care was provided to the member after the prior 
authorization was granted and before the provision of the dental care 
for which prior authorization was granted; 
 (b) The documentation provided by the person submitting the 
claim clearly fails to support the claim for which prior authorization 
was originally granted; 
 (c) After the prior authorization was granted, additional dental 
care was provided to the member or the condition of the member 
otherwise changed such that: 
  (1) The dental care for which prior authorization was granted 
is no longer medically necessary; or 
  (2) The organization for dental care or administrator, as 
applicable, would be required to deny prior authorization under the 
terms and conditions of the applicable plan for dental care that were 
in effect at the time of the provision of the dental care for which 
prior authorization was granted; 
 (d) Another person or entity is responsible for the payment; 
 (e) The dentist has previously been paid for the procedures 
covered by the claim; 
 (f) The claim was fraudulent or the prior authorization was 
based, in whole or in part, on materially false information provided 
by the dentist or member or another person who is not affiliated 
with the organization for dental care or administrator, as applicable; 
or 
 (g) The member was not eligible to receive the dental care for 
which the claim was made on the date that the dental care was 
provided.  
 2. Any provision of a contract that conflicts with this section is 
against public policy, void and unenforceable. 
 3. As used in this section: 
 (a) “Medically necessary” means dental care that a prudent 
dentist would provide to a patient to prevent, diagnose or treat an 
illness, injury or disease, or any symptoms thereof, that is necessary 
and: 
  (1) Provided in accordance with generally accepted standards 
of dental practice; 
  (2) Clinically appropriate with regard to type, frequency, 
extent, location and duration; 
  (3) Not primarily provided for the convenience of the patient 
or dentist;   
 	– 31 – 
 
 
- *AB290_R1* 
  (4) Required to improve a specific dental condition of a 
patient or to preserve the existing state of oral health of the patient; 
and 
  (5) The most clinically appropriate level of dental care that 
may be safely provided to the patient.  
 (b) “Prior authorization” means any communication issued by 
an organization for dental care or the administrator of a dental plan 
in response to a request by a dentist in the form prescribed by the 
organization for dental care or administrator, as applicable, which 
indicates that specific dental care provided to a patient is: 
  (1) Covered under the plan for dental care issued to the 
member; and 
  (2) Reimbursable in a specific amount, subject to applicable 
deductibles, copayments and coinsurance. 
 
H