Nevada Assembly Bill AB463 Introduced / Bill

                      
  
  	A.B. 463 
 
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ASSEMBLY BILL NO. 463–ASSEMBLYMEMBER BACKUS 
 
MARCH 17, 2025 
____________ 
 
Referred to Committee on Commerce and Labor 
 
SUMMARY—Revises provisions relating to prior authorization. 
(BDR 57-825) 
 
FISCAL NOTE: Effect on Local Government: May have Fiscal Impact. 
 Effect on the State: Yes. 
 
CONTAINS UNFUNDED MANDATE (§ 30) 
(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; prohibiting an 
insurer from requiring prior authorization for certain other 
medical care; requiring an insurer to publish certain 
information on the Internet website of the insurer; 
requiring an insurer and the Commissioner of Insurance to 
compile and submit 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 medical 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 
establishes additional requirements relating to the use of prior authorization for 7 
medical and dental care by health insurers, including Medicaid, the Children’s 8 
Health Insurance Program and insurance for public employees.  9 
 Specifically, sections 27 and 44 of this bill require that a procedure for 10 
obtaining prior authorization includes: (1) a list of the specific goods and services 11 
for which the insurer requires prior authorization; and (2) the clinical review 12 
criteria used by the insurer to evaluate requests for prior authorization. Sections 27 13 
and 44 also require an insurer to publish its procedure for obtaining prior 14   
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authorization on its Internet website and update that website as necessary to 15 
account for any changes in the procedure. Sections 27 and 44 prohibit an insurer 16 
from denying a claim for payment for medical or dental care because of the failure 17 
to obtain prior authorization if the insurer’s procedures for obtaining prior 18 
authorization in effect on the date on which the care was provided did not require 19 
prior authorization for that care. 20 
 Sections 27 and 45 of this bill revise the period for insurers to take action on a 21 
request for prior authorization by requiring an insurer to approve or deny such a 22 
request, or request additional, medically relevant information within: (1) 48 hours 23 
after receiving the request, for medical or dental care that is not urgent; or (2) 24 24 
hours after receiving the request, for care that is urgent. Sections 17 and 46 of this 25 
bill require any adverse determination on a request for prior authorization to be 26 
made by a physician or, for a request relating to dental care, a dentist, who is 27 
licensed in this State and possesses certain other qualifications. Sections 17 and 46 28 
require an insurer, in certain circumstances, to allow the provider of health care 29 
who requested the prior authorization to discuss the issues involved in the request 30 
with the physician or dentist who is responsible for making a determination on the 31 
request. Sections 17 and 46 require an insurer, upon making an adverse 32 
determination on a request for prior authorization, to transmit certain information to 33 
the insured to whom the request pertains, including information relating to the right 34 
of the insured to appeal the adverse determination. Sections 17 and 46 further 35 
require: (1) an insurer to establish a process for appeals that provides for the timely 36 
resolution of appeals submitted by insureds; and (2) a decision upholding an 37 
adverse determination on an appeal submitted by an insured to be made by a 38 
physician or dentist who has qualifications beyond those required of a physician or 39 
dentist who evaluates initial requests for prior authorization. 40 
 Sections 18 and 47 of this bill provide that a request for prior authorization that 41 
has been approved by the insurer remains valid for: (1) 12 months; or (2) treatment 42 
related to a chronic condition, until the standard of treatment for that condition 43 
changes. Sections 18 and 47 prohibit an insurer from requiring an insured to obtain 44 
additional prior authorization for a course of treatment or regimen of medication 45 
previously approved by the insurer. Section 18 requires an insurer to honor an 46 
approval of a request for prior authorization so long as the approval remains valid, 47 
even if the insured obtains coverage under a different policy issued by the insurer. 48 
Sections 18 and 47 also prohibit an insurer from denying or imposing additional 49 
limits on a request for prior authorization that the insurer has previously approved if 50 
the care at issue in the request is provided within 45 business days after the date on 51 
which the insurer receives the request and certain other requirements are met. 52 
Sections 18 and 47 require an insurer that approves a request for prior 53 
authorization to pay the provider of health care the full applicable rate for the 54 
relevant care, except in certain circumstances. Finally, Sections 18 and 47 require 55 
an insurer, for the first 90 days of the coverage period for a new insured, to honor a 56 
request for prior authorization that has been approved by the previous insurer of the 57 
new insured, under certain circumstances. 58 
 Sections 19, 48 and 55 of this bill prohibit an insurer from requiring an insured 59 
to obtain prior authorization for certain medical care, including certain preventive 60 
care services. Sections 20 and 49 of this bill prohibit an insurer from requiring 61 
prior authorization for covered emergency services. Sections 20 and 49 prohibit an 62 
insurer from requiring that an insured or provider of health care notify the insurer 63 
earlier than the end of the business day immediately following the date of 64 
admission or the date on which the emergency services are provided. Sections 20 65 
and 49 also require an insurer to respond to a request for prior authorization for 66 
certain follow-up care relating to the emergency care received by an insured within 67 
60 minutes after receiving the request. Finally, Sections 20 and 49: (1) prohibit an 68 
insurer from denying coverage for covered medically necessary emergency 69   
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services; and (2) establish a presumption of medical necessity under certain 70 
conditions. 71 
 Sections 24 and 55 of this bill require insurers to receive and respond to 72 
requests for prior authorization for prescription drugs through a secure transmission 73 
that complies with a standard established by the National Council for Prescription 74 
Drug Programs for the electronic transmission of pharmaceutical records. 75 
 Sections 21 and 50 of this bill require insurers to exempt providers of health 76 
care from the requirement to obtain prior authorization for specific goods and 77 
services if the insurer has granted requests for prior authorization for those goods or 78 
services submitted by the provider at a rate of 80 percent or more during the 79 
previous year. Sections 21 and 50 require insurers to annually conduct reviews of 80 
each provider of health care in the network of the insurer or who has submitted a 81 
request for prior authorization to Medicaid in the immediately preceding 12 82 
months, as applicable, to determine whether each such provider qualifies for an 83 
exemption. If the provider qualifies for an exemption, sections 21 and 50 require 84 
the insurer to automatically grant the exemption for the applicable goods and 85 
services, without requiring the provider to affirmatively request an exemption. 86 
Sections 22 and 51 of this bill prescribe the requirements and procedure for an 87 
insurer to revoke an exemption granted to a provider of health care. Sections 22 88 
and 51 also require an insurer to establish a procedure by which a provider of 89 
health care may appeal a revocation of an exemption. 90 
 Sections 3-16 and 35-43 of this bill define certain terms relating to the process 91 
of obtaining and processing requests for prior authorization, and sections 2 and 34 92 
of this bill establish the applicability of those definitions. Sections 23 and 52 of 93 
this bill provide that if an insurer violates any provision of section 17-20, 27 or 44-94 
49 with respect to a particular request for prior authorization, that the request is 95 
deemed approved. Sections 23 and 52 also clarify that nothing in any provision of 96 
section 17-22, 27 or 44-51 require an insurer to provide coverage: (1) for care that 97 
the insurer does not cover, regardless of the medical necessity of the care; or (2) to 98 
persons to whom the insured is not obligated to provide coverage. 99 
 Sections 25 and 53 of this bill require an insurer to annually publish on its 100 
Internet website certain information relating to requests for prior authorization that 101 
have been processed by the insurer during the immediately preceding year. 102 
Sections 26 and 54 of this bill additionally require an insurer to publish an annual 103 
report of certain information relating to requests for prior authorization processed 104 
by the insurer during the immediately preceding year.  105 
 Section 28 of this bill requires a nonprofit hospital and medical or dental 106 
service corporation to comply with sections 2-26. Section 29 of this bill requires 107 
the Director of the Department of Health and Human Services to administer the 108 
provisions of sections 33-54 of this bill in the same manner as other provisions 109 
governing Medicaid. Sections 30, 31 and 56 of this bill require plans of self-110 
insurance for employees of local governments, the Public Employees’ Benefits 111 
Program and plans of self-insurance for private employers, respectively, to comply 112 
with the requirements of sections 2-26 to the extent applicable. Section 33 provides 113 
that a managed care organization that provides services to recipients of Medicaid or 114 
the Children’s Health Insurance Program is not subject to sections 34-54, but must 115 
comply with sections 2-26. Section 55 requires the policies and procedures for 116 
coverage for prescription drugs under Medicaid to comply with sections 34-54. 117 
 
   
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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 26, inclusive, of this 2 
act. 3 
 Sec. 2.  As used in NRS 687B.225 and sections 2 to 26, 4 
inclusive, of this act, unless the context otherwise requires, the 5 
words and terms defined in sections 3 to 16, inclusive, of this act 6 
have the meanings ascribed to them in those sections. 7 
 Sec. 3.  “Adverse determination”: 8 
 1. Means a determination by a health carrier or a utilization 9 
review organization that the medical care or dental care furnished 10 
or proposed to be furnished to an insured is not medically 11 
necessary, or is experimental or investigational, and the requested 12 
care or payment for the care is therefore denied, reduced or 13 
terminated. 14 
 2. Does not include the denial, reduction or termination of 15 
coverage or payment for medical care or dental care for a reason 16 
other than the medical necessity or experimental or investigational 17 
nature of the medical care or dental care at issue in a request for 18 
prior authorization, including, without limitation, the denial of 19 
coverage for medical care or dental care that is not a covered 20 
benefit. 21 
 Sec. 4.  “Approval” means a determination by a health 22 
carrier or a utilization review organization that the medical care 23 
or dental care furnished or proposed to be furnished to an insured 24 
has been reviewed and, based on the information provided to the 25 
health carrier, satisfies the health carrier’s criteria for medical 26 
necessity or appropriateness and the requested care or payment 27 
for the care is therefore approved. 28 
 Sec. 5.  “Coverage period” means the current term of a 29 
contract or policy of insurance issued by a health carrier. 30 
 Sec. 6.  “Emergency medical services” means health care 31 
services that are provided in a medical facility by a provider of 32 
health care to screen and to stabilize an insured after the sudden 33 
onset of a medical condition that manifests itself by symptoms of 34 
such sufficient severity that a prudent layperson, who possesses 35 
average knowledge of health and medicine, would believe that the 36 
absence of immediate medical attention could result in: 37 
 1. Placing the health of the insured in serious jeopardy; 38 
 2. Placing the health of an unborn child of the insured in 39 
serious jeopardy; 40 
 3. A serious impairment of a bodily function of the insured; 41 
or 42   
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 4. A serious dysfunction of any bodily organ or part of the 1 
insured. 2 
 Sec. 7.  “Health carrier” has the meaning ascribed to it in 3 
NRS 695G.024, and includes, without limitation, an organization 4 
for dental care. The term additionally includes a utilization review 5 
organization, as defined in NRS 695G.085. 6 
 Sec. 8.  “Individually identifiable health information” means 7 
information relating to the provision of medical or dental care to 8 
an insured: 9 
 1. That specifically identifies the insured; or 10 
 2. For which there is a reasonable basis to believe that the 11 
information can be used to identify the insured. 12 
 Sec. 9.  “Insured” means a policyholder, subscriber, enrollee 13 
or other person covered by a health carrier. 14 
 Sec. 10.  “Medical facility” has the meaning ascribed to it in 15 
NRS 449.0151. 16 
 Sec. 11.  “Medically necessary” has the meaning ascribed to 17 
it in NRS 695G.055. 18 
 Sec. 12.  “Network” means a defined set of providers of 19 
health care who are under contract with a health carrier to 20 
provide health care services pursuant to a network plan offered or 21 
issued by the health carrier. 22 
 Sec. 13.  “Network plan” means a contract or policy of 23 
insurance offered by a health carrier under which the financing 24 
and delivery of medical or dental care is provided, in whole or in 25 
part, through a defined set of providers under contract with the 26 
health carrier. 27 
 Sec. 14.  “Prior authorization” means: 28 
 1. Any process by which a health carrier determines, before 29 
medical care or dental care that is otherwise covered by the health 30 
carrier is provided to an insured, that the medical care or dental 31 
care is medically necessary or medically appropriate with respect 32 
to the particular insured; or 33 
 2. Any requirement that an insured or a provider of health 34 
care of the insured notify the health carrier before medical or 35 
dental care is provided to the insured. 36 
 Sec. 15.  “Provider of health care” has the meaning ascribed 37 
to it in NRS 695G.070. 38 
 Sec. 16.  “Urgent health care”: 39 
 1. Means health care, including, without limitation, mental 40 
and behavioral care that, in the opinion of a provider of health 41 
care with knowledge of an insured’s medical condition, if not 42 
rendered to the insured within 48 hours could: 43 
 (a) Seriously jeopardize the life or health of the insured or the 44 
ability of the insured to regain maximum function; or 45   
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 (b) Subject the insured to severe pain that cannot be 1 
adequately managed without receiving such care. 2 
 2. Does not include emergency medical services. 3 
 Sec. 17.  1. A health carrier shall not make an adverse 4 
determination on a request for prior authorization unless: 5 
 (a) The adverse determination is made by a physician licensed 6 
pursuant to chapter 630 or 633 of NRS or, for dental care, a 7 
dentist licensed in this State who: 8 
  (1) Is of the same or similar specialty as a physician or 9 
dentist, as applicable, who typically manages or treats the medical 10 
or dental condition or provides the medical or dental care involved 11 
in the request; and 12 
  (2) Has experience treating or managing the medical or 13 
dental condition involved in the request; and 14 
 (b) The adverse determination is made under the clinical 15 
direction or supervision of a medical director employed by the 16 
health carrier who is a physician licensed pursuant to chapter 630 17 
or 633 of NRS. 18 
 2. If a physician or dentist described in paragraph (a) of 19 
subsection 1 is considering making an adverse determination on a 20 
request for prior authorization on the basis that the medical or 21 
dental care involved in the request is not medically necessary, the 22 
health carrier that received the request shall: 23 
 (a) Immediately notify the provider of health care who 24 
submitted the request that the medical necessity of the requested 25 
care is being questioned by the health carrier; and 26 
 (b) Offer the provider of health care an opportunity to speak 27 
with the physician or dentist, as applicable, over the telephone or 28 
by videoconference to discuss the clinical issues involved in the 29 
request before the physician or dentist renders an initial 30 
determination on the request. 31 
 3. Upon rendering an adverse determination on a request for 32 
prior authorization, a health carrier shall immediately transmit to 33 
the insured to whom the request pertains a written notice that 34 
contains: 35 
 (a) A specific description of all reasons that the health carrier 36 
made the adverse determination; 37 
 (b) A description of any documentation that the health carrier 38 
requested from the insured or a provider of health care of the 39 
insured and did not receive or deemed insufficient, if the failure to 40 
receive sufficient documentation contributed to the adverse 41 
determination; 42 
 (c) A statement that the insured has the right to appeal the 43 
adverse determination; 44   
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 (d) Instructions, written in clear language that is 1 
understandable to an ordinary layperson, describing how the 2 
insured can appeal the adverse determination through the process 3 
established pursuant to subsection 4; and 4 
 (e) A description of any documentation that may be necessary 5 
or pertinent to a potential appeal. 6 
 4. A health carrier shall establish a process that allows an 7 
insured to appeal an adverse determination on a request for prior 8 
authorization. The process must allow for the clear resolution of 9 
each appeal within a reasonable time. 10 
 5. A health carrier shall not uphold on appeal an adverse 11 
determination pertaining to a request for prior authorization 12 
unless the decision on the appeal is made by a physician licensed 13 
pursuant to chapter 630 or 633 of NRS or, for dental care, a 14 
dentist licensed in this State who: 15 
 (a) Is actively practicing medicine or dentistry, as applicable, 16 
within the same or similar specialty as a physician or dentist, as 17 
applicable, who typically manages or treats the medical or dental 18 
condition or provides the medical or dental care involved in the 19 
request and has been actively practicing in that specialty for at 20 
least 5 consecutive years preceding the date on which the 21 
physician or dentist, as applicable, makes the determination on the 22 
appeal; 23 
 (b) Is knowledgeable of and has experience treating or 24 
managing the medical or dental condition involved in the request; 25 
 (c) Was not involved in making the adverse determination that 26 
is the subject of the appeal; 27 
 (d) Has no financial interest in the outcome of the request for 28 
prior authorization that is the subject of the appeal; 29 
 (e) Is not employed by or contracted with the health carrier 30 
except: 31 
  (1) To participate in the network of the health carrier in his 32 
or her capacity as a practicing physician or dentist, as applicable; 33 
  (2) To make determinations on reviews or appeals of 34 
adverse determinations; or 35 
  (3) For the purposes described in both subparagraphs (1) 36 
and (2); and 37 
 (f) Considers all known clinical aspects of the medical or 38 
dental care involved in the request, including, without limitation: 39 
  (1) The medical records of the insured that are provided or 40 
accessible to the health carrier, including those records provided 41 
to the health carrier by the insured or a provider of health care of 42 
the insured; 43 
  (2) The clinical review criteria adopted by the health carrier 44 
pursuant to subsection 2 of NRS 687B.225; and 45   
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  (3) Medical or scientific evidence provided to the health 1 
carrier by the provider of health care who requested prior 2 
authorization for the care at issue. 3 
 6. As used in this section, “medical or scientific evidence” 4 
has the meaning ascribed to it in NRS 695G.053. 5 
 Sec. 18.  1. Except as otherwise provided in subsection 3, if 6 
a health carrier approves a request for prior authorization, the 7 
approval remains valid until: 8 
 (a) Twelve months after the date on which the request is 9 
approved; or 10 
 (b) If the approval relates to the treatment of a chronic 11 
condition, until the standard of treatment for that condition 12 
changes. 13 
 2. If an insured to whom a request for prior authorization has 14 
been approved by a health carrier obtains coverage under a 15 
different policy or contract of health insurance issued by the same 16 
health carrier, the health carrier shall honor the approval to the 17 
same extent as if the insured were still covered under the policy or 18 
contract of health insurance under which the insured was covered 19 
when the health carrier approved the request. 20 
 3. If a health carrier has previously granted prior 21 
authorization for a course of care or regimen of medication 22 
ordered or prescribed for an insured, the health carrier shall not 23 
require the insured to obtain additional prior authorization for the 24 
course of care or regimen for prescription drugs previously 25 
approved by the health carrier. 26 
 4. 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 care at issue in the request is provided to the insured 30 
within 45 business days after the date on which the health carrier 31 
received the request; 32 
 (b) The health carrier determines that an insured or provider 33 
of health care procured the approval by fraud or material 34 
misrepresentation; or 35 
 (c) The health carrier determines that the care at issue in the 36 
request was not a covered benefit. 37 
 5. A health carrier that has approved a request for prior 38 
authorization shall promptly pay a provider of health care for a 39 
claim for the approved medical or dental care at the full 40 
contracted payment rate between the provider of health care and 41 
health carrier unless: 42 
 (a) The provider of health care knowingly and materially 43 
misrepresented the medical care or dental care contained in the 44 
request with the specific intent to deceive and obtain a payment 45   
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from the health carrier to which the provider of health care was 1 
not entitled; 2 
 (b) The provider of health care was not participating in the 3 
network of the health carrier on the date that the care was 4 
provided; 5 
 (c) The claim for the medical or dental care was not timely 6 
submitted in accordance with the applicable terms and conditions 7 
of the policy or contract of health insurance issued by the health 8 
carrier; or 9 
 (d) The health carrier is not required to provide coverage for 10 
any reason listed in subsection 2 of section 23 of this act. 11 
 6. Within the first 90 days of the coverage period for an 12 
insured, a health carrier shall honor a request for prior 13 
authorization that has been approved by a health carrier or other 14 
entity that previously provided the insured with coverage for 15 
medical or dental care if: 16 
 (a) The approval was issued within the 12 months immediately 17 
preceding the first day of the coverage period under the current 18 
contract or policy of insurance; and 19 
 (b) The specific medical or dental care included within the 20 
request is not affirmatively excluded under the terms and 21 
conditions of the contract or policy of insurance issued by the 22 
health carrier. 23 
 7. A health carrier may undertake an independent review of 24 
the care approved by the previous health carrier of an insured 25 
which is subject to the requirements of subsection 6 for the 26 
purpose of granting its own approval of the care. A health carrier 27 
shall not deny approval in violation of subsection 6 as the result of 28 
such a review. 29 
 8. As used in this section, “chronic condition” means a 30 
condition that is expected to last 1 year or more and: 31 
 (a) Requires ongoing medical attention to effectively manage 32 
the condition or prevent an event that adversely affects the health 33 
of the person; or 34 
 (b) Limits one or more activities of daily living. 35 
 Sec. 19.  1. A health carrier shall not require prior 36 
authorization for: 37 
 (a) Outpatient services for the treatment of a mental health 38 
condition or substance use disorder. 39 
 (b) Antineoplastic treatment for cancer, other than 40 
prescription drugs, that is consistent with the guidelines 41 
established by the National Comprehensive Cancer Network, or its 42 
successor organization. 43   
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 (c) Evidence-based goods or services for preventive care that 1 
have in effect a grade of “A” or “B” identified by the United 2 
States Preventive Services Task Force. 3 
 (d) Preventive care for women described in 45 C.F.R. § 4 
147.130(a)(iv). 5 
 (e) Hospice care provided to pediatric patients in a facility for 6 
hospice care licensed pursuant to chapter 449 of NRS. 7 
 (f) Care provided to treat neonatal abstinence syndrome 8 
provided by a provider of health care who specializes in pain 9 
management for pediatric patients or palliative care provided to 10 
pediatric patients. 11 
 2. As used in this section: 12 
 (a) “Facility for hospice care” has the meaning ascribed to it 13 
in NRS 449.0033. 14 
 (b) “Hospice care” has the meaning ascribed to it in  15 
NRS 449.0115. 16 
 Sec. 20.  1. A health carrier shall not require prior 17 
authorization for emergency medical services covered by the 18 
health carrier, including, where applicable, transportation by 19 
ambulance to a hospital or other medical facility. 20 
 2. If a health carrier requires an insured or his or her 21 
provider of health care to notify the health carrier that the insured 22 
has been admitted to a hospital to receive emergency medical 23 
services or has received emergency medical services, the health 24 
carrier shall not require an insured or a provider of health care to 25 
transmit such a notice earlier than the end of the business day 26 
immediately following the date on which the insured was admitted 27 
or the emergency medical services were provided, as applicable. 28 
 3. A health carrier shall not deny coverage for emergency 29 
medical services covered by the health carrier that are medically 30 
necessary. Emergency medical services are presumed to be 31 
medically necessary if, within 72 hours after an insured is 32 
admitted to receive emergency medical services, the provider of 33 
health care of the insured transmits to the health carrier a 34 
certification, in writing, that the condition of the insured required 35 
emergency medical services. The health carrier may rebut that 36 
presumption by establishing, by clear and convincing evidence, 37 
that the emergency medical services were not medically necessary. 38 
 4. If an insured receives emergency medical services and 39 
must additionally receive post-evaluation or post-stabilization 40 
medical care, and a health carrier requires prior authorization for 41 
the post-evaluation or post-stabilization care, the health carrier 42 
shall approve or deny a request for prior authorization for such 43 
care within 60 minutes after receiving the request. 44   
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 5. A health carrier shall make all determinations for whether 1 
emergency medical services are medically necessary without 2 
regard to whether a provider of health care that provided or billed 3 
for those services participates in the network of the health carrier. 4 
 Sec. 21.  1. A health carrier shall exempt a provider of 5 
health care who participates in the network of the health carrier 6 
from the requirement to obtain prior authorization for a specific 7 
good or service if, within the immediately preceding 12 months, 8 
the health carrier approved 80 percent or more of the requests for 9 
prior authorization for that specific good or service submitted by 10 
the provider of health care. If a provider of health care qualifies 11 
for an exemption pursuant to this section, a health carrier shall: 12 
 (a) Automatically grant the exemption without requiring the 13 
provider of health care to submit a request for the exemption; and 14 
 (b) Transmit to the provider of health care after granting the 15 
exemption a notice that includes: 16 
  (1) A statement that the provider of health care has been 17 
granted an exemption from the requirement to obtain prior 18 
authorization from the health carrier for the specific goods and 19 
services listed pursuant to subparagraph (2); 20 
  (2) A list of goods and services to which the exemption 21 
applies; and 22 
  (3) The date on which the exemption expires, which must 23 
not be earlier than 12 months after the date on which the health 24 
carrier granted the exemption. 25 
 2. A health carrier shall provide for an annual review of the 26 
requests for prior authorization submitted by providers of health 27 
care who participate in the network of the health carrier to 28 
determine whether those providers meet the criteria prescribed by 29 
subsection 1 for an exemption from the requirement to obtain 30 
prior authorization. If a provider of health care is initially 31 
determined to be ineligible for an exemption based on such a 32 
review, the eligibility of the provider of health care to receive an 33 
exemption must be independently determined by a provider of 34 
health care who: 35 
 (a) Is licensed in this State; 36 
 (b) Is of the same or similar specialty as the provider of health 37 
care who is being evaluated for an exemption; and 38 
 (c) Has experience providing the good or service for which the 39 
exemption has been initially denied. 40 
 3. A provider of health care who is not granted an exemption 41 
from the requirement to obtain prior authorization for a particular 42 
good or service may, for that specific good or service, request from 43 
the health carrier any evidence that supported the decision of the 44 
health carrier to not grant the exemption for that good or service. 45   
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A provider of health care may submit a request for supporting 1 
evidence pursuant to this subsection not more than once during a 2 
single 12-month period for each good or service for which the 3 
provider of health care has not been granted an exemption. 4 
 4. An exemption from the requirement to obtain prior 5 
authorization pursuant to this section applies to the provision of 6 
any good or service covered by the exemption which is provided or 7 
ordered by the provider of health care to whom the exception 8 
applies. 9 
 5. A health carrier shall not deny a claim or reduce the 10 
amount of payment paid under a claim for a good or service that is 11 
subject to an exemption pursuant to this section unless: 12 
 (a) The provider of health care who submitted the claim 13 
knowingly and materially misrepresented the goods or services 14 
actually provided to an insured, and the provider of health care 15 
made the misrepresentation with the specific intent to obtain a 16 
payment from the health carrier to which the provider of health 17 
care is not legally or contractually entitled; or 18 
 (b) The service or good for which payment is sought was not 19 
substantially performed or provided, as applicable. 20 
 Sec. 22.  1. Not more than once during a single 12-month 21 
period, a health carrier may reevaluate the eligibility of a provider 22 
of health care to receive an exemption from the requirement to 23 
obtain prior authorization pursuant to section 21 of this act. 24 
 2. A health carrier may, pursuant to subsection 1, revoke an 25 
exemption from the requirement to obtain prior authorization 26 
granted to a provider of health care only if the health carrier 27 
determines that the provider of health care would not have met the 28 
criteria prescribed in subsection 1 of section 21 of this act for the 29 
good or service to which the exemption applies based on: 30 
 (a) A retrospective review of claims submitted by the provider 31 
of health care for that good or service during the immediately 32 
preceding 3 months; or 33 
 (b) If the provider of health care did not submit at least 10 34 
claims for that good or service during the immediately preceding 3 35 
months, a retrospective review of at least the last 10 claims 36 
submitted by the provider of health care for that good or service. 37 
 3. If it is initially determined that a provider of health care 38 
meets the criteria prescribed in subsection 2 for the revocation of 39 
an exemption based on a review conducted pursuant to that 40 
subsection, the satisfaction of those criteria must be independently 41 
determined by a provider of health care described in subsection 2 42 
of section 21 of this act before the health carrier may revoke the 43 
exemption. 44   
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 4.  A health carrier that revokes an exemption from the 1 
requirement to obtain prior authorization pursuant to subsection 2 2 
shall transmit to the provider of health care to which the 3 
revocation pertains a notice that includes: 4 
 (a) The information that the health carrier relied upon when 5 
making the determination described in subsection 2; 6 
 (b) An identification of each good or service to which the 7 
revoked exemption applies; 8 
 (c) The date on which the revocation takes effect, which must 9 
not be earlier than 30 days after the date on which the health 10 
carrier transmits the notice; and 11 
 (d) A description, written in easily comprehensible language, 12 
of how the provider of health care may appeal the revocation 13 
pursuant to subsection 5. 14 
 5. A health carrier shall adopt a procedure by which a 15 
provider of health care may appeal the revocation of an exemption 16 
from the requirement to obtain prior authorization. If a provider 17 
of health care appeals a revocation of such exemption, the 18 
exemption must remain in effect: 19 
 (a) If the revocation is reversed on appeal, until the next 20 
reevaluation pursuant to subsection 1 of the eligibility of the 21 
provider of health care to continue receiving the exemption. 22 
 (b) If the revocation is upheld on appeal, until the later of the 23 
5th calendar day after the revocation is upheld or the date 24 
contained within the notice sent to the provider of health care 25 
pursuant to subsection 4. 26 
 Sec. 23.  1. If a health carrier violates NRS 687B.225 or 27 
sections 17 to 20, inclusive, of this act with respect to a particular 28 
request for prior authorization, the request shall be deemed 29 
approved. 30 
 2. Nothing in NRS 687B.225 or sections 17 to 22, inclusive, 31 
of this act shall be construed to require a health carrier to provide 32 
coverage: 33 
 (a) For medical or dental care that, regardless of whether such 34 
care is medically necessary, would not be a covered benefit under 35 
the terms and conditions of the contract or policy of insurance; 36 
 (b) To a person who is not insured by the health carrier on the 37 
date on which medical or dental care is provided to the person; or 38 
 (c) To an insured who, as a result of his or her failure to pay 39 
the applicable premiums required under the terms and conditions 40 
of a contract or policy of insurance, has no coverage under the 41 
contract or policy on the date on which medical or dental care is 42 
provided to the insured. 43 
 Sec. 24.  A health carrier that requires prior authorization for 44 
prescription drugs shall accept and respond to any request for 45   
 	– 14 – 
 
 
- 	*AB463* 
prior authorization for a prescription drug through a secure 1 
electronic transmission using the National Council for 2 
Prescription Drug Programs SCRIPT standard described in 42 3 
C.F.R. § 423.160(b). 4 
 Sec. 25.  1. On or before March 1 of each calendar year, a 5 
health carrier shall publish on an Internet website maintained by 6 
the health carrier in an easily accessible format the following 7 
information for the immediately preceding calendar year, in 8 
aggregated form for all requests for prior authorization received 9 
by the health carrier during the immediately preceding year and 10 
disaggregated in accordance with subsection 2: 11 
 (a) The percentage of requests for prior authorization for 12 
medical or dental care in this State that were approved upon initial 13 
review; 14 
 (b) The percentage of requests for prior authorization for 15 
medical or dental care in this State that resulted in an adverse 16 
determination upon initial review; 17 
 (c) The percentage of the adverse determinations described in 18 
paragraph (b) that were appealed; 19 
 (d) The percentage of appeals of adverse determinations 20 
described in paragraph (c) that resulted in a reversal of the 21 
adverse determination; 22 
 (e) The five most common reasons for the adverse 23 
determinations described in paragraph (b); and 24 
 (f) The average time between a request for prior authorization 25 
for medical or dental care in this State and the resolution of the 26 
request. 27 
 2. The information described in subsection 1 must be 28 
disaggregated for the following categories: 29 
 (a) The specialty of the provider of health care who submitted 30 
a request for prior authorization; and 31 
 (b) The types of medical or dental care at issue in the request 32 
for prior authorization, including the specific types of prescription 33 
drugs, procedures or diagnostic tests involved in the requests. 34 
 3. A health carrier shall not include individually identifiable 35 
health information in the information published pursuant to 36 
subsection 1. 37 
 Sec. 26.  1. On or before March 1 of each calendar year, a 38 
health carrier shall compile and transmit to the Commissioner, in 39 
a form prescribed by the Commissioner, and publish on an 40 
Internet website maintained by the health carrier a report 41 
containing the following information: 42 
 (a) The specific goods and services for which the health 43 
carrier requires prior authorization and, for each good or service: 44   
 	– 15 – 
 
 
- 	*AB463* 
  (1) The date on which prior authorization for that good or 1 
service became required for contracts or policies issued or 2 
delivered in this State and the date on which that requirement was 3 
listed on the Internet website of the health carrier pursuant to 4 
subsection 6 of NRS 687B.225; 5 
  (2) The number of requests for prior authorization received 6 
by the health carrier during the immediately preceding calendar 7 
year for the provision of the good or service to insureds in this 8 
State; 9 
  (3) The number and percentage of the requests listed 10 
pursuant to subparagraph (2) that were approved; 11 
  (4) The number and percentage of the requests listed 12 
pursuant to subparagraph (2) that resulted in adverse 13 
determinations; and 14 
  (5) The number of appeals from adverse determinations 15 
during the immediately preceding calendar year and the number 16 
and percentage of those appeals that were reversed on appeal by 17 
the health carrier. 18 
 (b) The information described in subparagraphs (2) to (5), 19 
inclusive, aggregated for all requests for prior authorization 20 
received by the health carrier during the immediately preceding 21 
calendar year. 22 
 (c) A list of each reason that the health carrier issued an 23 
adverse determination on a request for prior authorization during 24 
the immediately preceding calendar year, and the percentage for 25 
which each reason listed accounts for all adverse determinations 26 
issued by the health carrier during the immediately preceding 27 
calendar year. 28 
 (d) For all requests for prior authorization for non-urgent 29 
medical or dental care received by the health carrier during the 30 
immediately preceding calendar year, the average and median 31 
time between: 32 
  (1) The health carrier receiving a request for prior 33 
authorization and the health carrier approving or making an 34 
adverse determination on the request; and 35 
  (2) The submission of an appeal of an adverse 36 
determination on a request for prior authorization and the 37 
resolution of the appeal. 38 
 (e) For all requests for prior authorization for urgent health 39 
care received by the health carrier during the immediately 40 
preceding calendar year, the average and median time between: 41 
  (1) The health carrier receiving a request for prior 42 
authorization and the health carrier approving or making an 43 
adverse determination on the request; and 44   
 	– 16 – 
 
 
- 	*AB463* 
  (2) The submission of an appeal of an adverse 1 
determination on a request for prior authorization and the 2 
resolution of the appeal. 3 
 (f) Such additional information as the Commissioner may 4 
prescribe by regulation. 5 
 2. On or before May 1 of each even-numbered year, the 6 
Commissioner shall: 7 
 (a) Compile a report: 8 
  (1) Summarizing the information submitted to the 9 
Commissioner pursuant to subsection 1 during the immediately 10 
preceding biennium; 11 
  (2) Listing the specific goods and services for which health 12 
carriers approved requests for prior authorization for insureds in 13 
this State at a combined rate of 80 percent or more during the 14 
immediately preceding biennium; and 15 
  (3) Recommending legislation to prohibit health carriers 16 
from requiring prior authorization for the specific goods and 17 
services listed pursuant to subparagraph (2); and 18 
 (b) Submit the report and all information provided to the 19 
Commissioner pursuant to subsection 1 to the Director of the 20 
Legislative Counsel Bureau for transmittal to the Joint Interim 21 
Standing Committee on Health and Human Services and the Joint 22 
Interim Standing Committee on Commerce and Labor. 23 
 3. A health carrier shall not include individually identifiable 24 
health information in a report published pursuant to subsection 1. 25 
 Sec. 27.  NRS 687B.225 is hereby amended to read as follows: 26 
 687B.225 1.  Except as otherwise provided in NRS 27 
689A.0405, 689A.0412, 689A.0413, 689A.0418, 689A.0437, 28 
689A.044, 689A.0445, 689A.0459, 689B.031, 689B.0312, 29 
689B.0313, 689B.0315, 689B.0317, 689B.0319, 689B.0374, 30 
689B.0378, 689C.1665, 689C.1671, 689C.1675, 689C.1676, 31 
695A.1843, 695A.1856, 695A.1865, 695A.1874, 695B.1912, 32 
695B.1913, 695B.1914, 695B.1919, 695B.19197, 695B.1924, 33 
695B.1925, 695B.1942, 695C.1696, 695C.1699, 695C.1713, 34 
695C.1735, 695C.1737, 695C.1743, 695C.1745, 695C.1751, 35 
695G.170, 695G.1705, 695G.171, 695G.1714, 695G.1715, 36 
695G.1719 and 695G.177, and sections 18 to 21, inclusive, of this 37 
act, any contract [for group, blanket or individual health] or policy 38 
of insurance [or any contract by a nonprofit hospital, medical or 39 
dental service corporation or organization for dental care] issued by 40 
a health carrier which provides for payment of a certain part of 41 
medical or dental care may require the insured [or member] to 42 
obtain prior authorization for that care from the [insurer or 43 
organization. The insurer or organization] health carrier in a 44   
 	– 17 – 
 
 
- 	*AB463* 
manner consistent with this section and sections 2 to 26, inclusive, 1 
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 specific goods and services for which the 7 
health carrier requires prior authorization and the clinical review 8 
criteria 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 deny any request for [approval by the insured or 15 
member] prior authorization submitted by or on behalf of the 16 
insured pursuant to this section [within 20 days after it receives the 17 
request.] and notify the insured and his or her provider of health 18 
care of the approval or denial: 19 
  (1) For non-urgent medical or dental care, within 48 hours 20 
after receiving the request. 21 
  (2) For urgent health care, within 24 hours after receiving 22 
the request. 23 
 (c) If the health carrier requires additional, medically relevant 24 
information or documentation, including, without limitation, an 25 
in-person clinical evaluation of the insured or a second opinion 26 
from a different provider of health care, in order to adequately 27 
evaluate a request for prior authorization: 28 
  (1) Notify the insured and the provider of health care who 29 
submitted the request within the applicable amount of time 30 
described in paragraph (b) that additional information is required 31 
to evaluate the request; 32 
  (2) Include within the notification sent pursuant to 33 
subparagraph (1) a description, with reasonable specificity, of the 34 
information that the health carrier requires to make a 35 
determination on the request for prior authorization; and 36 
  (3) Approve or deny the request: 37 
   (I) For non-urgent medical or dental care, within 48 38 
hours after receiving the information. 39 
   (II) For urgent health care, within 24 hours after 40 
receiving the information. 41 
 [2.] 3.  The procedure for prior authorization may not 42 
discriminate among persons licensed to provide the covered care. 43 
 4. If a health carrier seeks to amend its procedure for 44 
obtaining prior authorization, including, without limitation, 45   
 	– 18 – 
 
 
- 	*AB463* 
changing the goods and services for which the health carrier 1 
requires prior authorization or changing the clinical review 2 
criteria used by the health carrier, the health carrier: 3 
 (a) Must file a request to amend the procedure for approval by 4 
the Commissioner. 5 
 (b) May not allow the amended procedure to take effect until: 6 
  (1) The Commissioner notifies the health carrier that the 7 
request is approved; and 8 
  (2) The requirements of subsection 5 are satisfied. 9 
 5. Except as otherwise provided in subsection 8, a change to a 10 
health carrier’s procedure for obtaining prior authorization may 11 
not take effect until: 12 
 (a) The health carrier transmits a notice that contains a 13 
summary of the changes to the procedure to each of its insureds 14 
and providers of health care who participate in the network of the 15 
health carrier; 16 
 (b) The health carrier updates the information published on its 17 
Internet website pursuant to subsection 6 to reflect the amended 18 
procedure for obtaining prior authorization and the date on which 19 
the amended procedure takes effect; and 20 
 (c) At least 60 days have passed after the later of: 21 
  (1) The date on which the health carrier transmitted the 22 
notice to its insureds and providers of health care who participate 23 
in the network of the health carrier pursuant to paragraph (a); or 24 
  (2) The date on which the health carrier updated the 25 
information published on its Internet website pursuant to 26 
paragraph (b). 27 
 6. A health carrier shall publish its procedures for obtaining 28 
prior authorization, including, without limitation, the clinical 29 
review criteria, on its Internet website: 30 
 (a) Using clear language that is understandable to an ordinary 31 
layperson, where practicable; and 32 
 (b) In a place that is readily accessible and conspicuous to 33 
insureds and the public. 34 
 7. A health carrier shall not deny a claim based on the failure 35 
of an insured to obtain prior authorization for medical or dental 36 
care if the procedure for obtaining prior authorization established 37 
by the health carrier did not require the insured to obtain prior 38 
authorization for that medical or dental care on the date on which 39 
the medical or dental care was provided to the insured. 40 
 8. A change in the health carrier’s procedure for obtaining 41 
prior authorization or a new exclusion or limitation of coverage 42 
adopted by a health carrier may not take effect until the next 43 
coverage period with respect to: 44   
 	– 19 – 
 
 
- 	*AB463* 
 (a) An insured for whom the health carrier has, within the 1 
current coverage period, approved a request for prior 2 
authorization; and 3 
 (b) Medical or dental care that is identical to the care for 4 
which the health carrier had previously approved a request for 5 
prior authorization within the current coverage period. 6 
 9. As used in this section, “clinical review criteria” means 7 
any written screening procedure, formulary, decision abstract, 8 
clinical protocol, practice guideline or other criteria used by the 9 
health carrier to determine the necessity and appropriateness of 10 
medical or dental care. 11 
 Sec. 28.  NRS 695B.320 is hereby amended to read as follows: 12 
 695B.320 1.  Nonprofit hospital and medical or dental service 13 
corporations are subject to the provisions of this chapter, and to the 14 
provisions of chapters 679A and 679B of NRS, subsections 2, 4, 17, 15 
18 and 30 of NRS 680B.010, NRS 680B.025 to 680B.060, 16 
inclusive, chapter 681B of NRS, NRS 686A.010 to 686A.315, 17 
inclusive, 686B.010 to 686B.175, inclusive, 687B.010 to  18 
687B.040, inclusive, 687B.070 to 687B.140, inclusive, 687B.150, 19 
687B.160, 687B.180, 687B.200 to 687B.255, inclusive, and 20 
sections 2 to 26, inclusive, of this act, 687B.270, 687B.310 to 21 
687B.380, inclusive, 687B.410, 687B.420, 687B.430, 687B.500 and 22 
chapters 692B, 692C, 693A and 696B of NRS, to the extent 23 
applicable and not in conflict with the express provisions of this 24 
chapter. 25 
 2. For the purposes of this section and the provisions set forth 26 
in subsection 1, a nonprofit hospital and medical or dental service 27 
corporation is included in the meaning of the term “insurer.” 28 
 Sec. 29.  NRS 232.320 is hereby amended to read as follows: 29 
 232.320 1.  The Director: 30 
 (a) Shall appoint, with the consent of the Governor, 31 
administrators of the divisions of the Department, who are 32 
respectively designated as follows: 33 
  (1) The Administrator of the Aging and Disability Services 34 
Division; 35 
  (2) The Administrator of the Division of Welfare and 36 
Supportive Services; 37 
  (3) The Administrator of the Division of Child and Family 38 
Services; 39 
  (4) The Administrator of the Division of Health Care 40 
Financing and Policy; and 41 
  (5) The Administrator of the Division of Public and 42 
Behavioral Health. 43 
 (b) Shall administer, through the divisions of the Department, 44 
the provisions of chapters 63, 424, 425, 427A, 432A to 442, 45   
 	– 20 – 
 
 
- 	*AB463* 
inclusive, 446 to 450, inclusive, 458A and 656A of NRS,  1 
NRS 127.220 to 127.310, inclusive, 422.001 to 422.410, inclusive, 2 
and sections 33 to 54, inclusive, of this act, 422.580, 432.010 to 3 
432.133, inclusive, 432B.6201 to 432B.626, inclusive, 444.002 to 4 
444.430, inclusive, and 445A.010 to 445A.055, inclusive, and all 5 
other provisions of law relating to the functions of the divisions of 6 
the Department, but is not responsible for the clinical activities of 7 
the Division of Public and Behavioral Health or the professional line 8 
activities of the other divisions. 9 
 (c) Shall administer any state program for persons with 10 
developmental disabilities established pursuant to the 11 
Developmental Disabilities Assistance and Bill of Rights Act of 12 
2000, 42 U.S.C. §§ 15001 et seq. 13 
 (d) Shall, after considering advice from agencies of local 14 
governments and nonprofit organizations which provide social 15 
services, adopt a master plan for the provision of human services in 16 
this State. The Director shall revise the plan biennially and deliver a 17 
copy of the plan to the Governor and the Legislature at the 18 
beginning of each regular session. The plan must: 19 
  (1) Identify and assess the plans and programs of the 20 
Department for the provision of human services, and any 21 
duplication of those services by federal, state and local agencies; 22 
  (2) Set forth priorities for the provision of those services; 23 
  (3) Provide for communication and the coordination of those 24 
services among nonprofit organizations, agencies of local 25 
government, the State and the Federal Government; 26 
  (4) Identify the sources of funding for services provided by 27 
the Department and the allocation of that funding; 28 
  (5) Set forth sufficient information to assist the Department 29 
in providing those services and in the planning and budgeting for the 30 
future provision of those services; and 31 
  (6) Contain any other information necessary for the 32 
Department to communicate effectively with the Federal 33 
Government concerning demographic trends, formulas for the 34 
distribution of federal money and any need for the modification of 35 
programs administered by the Department. 36 
 (e) May, by regulation, require nonprofit organizations and state 37 
and local governmental agencies to provide information regarding 38 
the programs of those organizations and agencies, excluding 39 
detailed information relating to their budgets and payrolls, which the 40 
Director deems necessary for the performance of the duties imposed 41 
upon him or her pursuant to this section. 42 
 (f) Has such other powers and duties as are provided by law. 43   
 	– 21 – 
 
 
- 	*AB463* 
 2.  Notwithstanding any other provision of law, the Director, or 1 
the Director’s designee, is responsible for appointing and removing 2 
subordinate officers and employees of the Department. 3 
 Sec. 30.  NRS 287.010 is hereby amended to read as follows: 4 
 287.010 1.  The governing body of any county, school 5 
district, municipal corporation, political subdivision, public 6 
corporation or other local governmental agency of the State of 7 
Nevada may: 8 
 (a) Adopt and carry into effect a system of group life, accident 9 
or health insurance, or any combination thereof, for the benefit of its 10 
officers and employees, and the dependents of officers and 11 
employees who elect to accept the insurance and who, where 12 
necessary, have authorized the governing body to make deductions 13 
from their compensation for the payment of premiums on the 14 
insurance. 15 
 (b) Purchase group policies of life, accident or health insurance, 16 
or any combination thereof, for the benefit of such officers and 17 
employees, and the dependents of such officers and employees, as 18 
have authorized the purchase, from insurance companies authorized 19 
to transact the business of such insurance in the State of Nevada, 20 
and, where necessary, deduct from the compensation of officers and 21 
employees the premiums upon insurance and pay the deductions 22 
upon the premiums. 23 
 (c) Provide group life, accident or health coverage through a 24 
self-insurance reserve fund and, where necessary, deduct 25 
contributions to the maintenance of the fund from the compensation 26 
of officers and employees and pay the deductions into the fund. The 27 
money accumulated for this purpose through deductions from the 28 
compensation of officers and employees and contributions of the 29 
governing body must be maintained as an internal service fund as 30 
defined by NRS 354.543. The money must be deposited in a state or 31 
national bank or credit union authorized to transact business in the 32 
State of Nevada. Any independent administrator of a fund created 33 
under this section is subject to the licensing requirements of chapter 34 
683A of NRS, and must be a resident of this State. Any contract 35 
with an independent administrator must be approved by the 36 
Commissioner of Insurance as to the reasonableness of 37 
administrative charges in relation to contributions collected and 38 
benefits provided. The provisions of NRS 439.581 to 439.597, 39 
inclusive, 686A.135, paragraphs (b) and (c) of subsection 2 of 40 
NRS 687B.225, subsections 1, 3 and 5 to 8, inclusive, of NRS 41 
687B.225, 687B.352, 687B.408, 687B.692, 687B.723, 687B.725, 42 
687B.805, 689B.030 to 689B.0317, inclusive, paragraphs (b) and (c) 43 
of subsection 1 of NRS 689B.0319, subsections 2, 4, 6 and 7 of 44 
NRS 689B.0319, 689B.033 to 689B.0369, inclusive, 689B.0375 to 45   
 	– 22 – 
 
 
- 	*AB463* 
689B.050, inclusive, 689B.0675, 689B.265, 689B.287 and 1 
689B.500 and sections 2 to 26, inclusive, of this act apply to 2 
coverage provided pursuant to this paragraph, except that the 3 
provisions of NRS 689B.0378, 689B.03785 and 689B.500 only 4 
apply to coverage for active officers and employees of the 5 
governing body, or the dependents of such officers and employees. 6 
 (d) Defray part or all of the cost of maintenance of a self-7 
insurance fund or of the premiums upon insurance. The money for 8 
contributions must be budgeted for in accordance with the laws 9 
governing the county, school district, municipal corporation, 10 
political subdivision, public corporation or other local governmental 11 
agency of the State of Nevada. 12 
 2.  If a school district offers group insurance to its officers and 13 
employees pursuant to this section, members of the board of trustees 14 
of the school district must not be excluded from participating in the 15 
group insurance. If the amount of the deductions from compensation 16 
required to pay for the group insurance exceeds the compensation to 17 
which a trustee is entitled, the difference must be paid by the trustee. 18 
 3.  In any county in which a legal services organization exists, 19 
the governing body of the county, or of any school district, 20 
municipal corporation, political subdivision, public corporation or 21 
other local governmental agency of the State of Nevada in the 22 
county, may enter into a contract with the legal services 23 
organization pursuant to which the officers and employees of the 24 
legal services organization, and the dependents of those officers and 25 
employees, are eligible for any life, accident or health insurance 26 
provided pursuant to this section to the officers and employees, and 27 
the dependents of the officers and employees, of the county, school 28 
district, municipal corporation, political subdivision, public 29 
corporation or other local governmental agency. 30 
 4.  If a contract is entered into pursuant to subsection 3, the 31 
officers and employees of the legal services organization: 32 
 (a) Shall be deemed, solely for the purposes of this section, to be 33 
officers and employees of the county, school district, municipal 34 
corporation, political subdivision, public corporation or other local 35 
governmental agency with which the legal services organization has 36 
contracted; and 37 
 (b) Must be required by the contract to pay the premiums or 38 
contributions for all insurance which they elect to accept or of which 39 
they authorize the purchase. 40 
 5.  A contract that is entered into pursuant to subsection 3: 41 
 (a) Must be submitted to the Commissioner of Insurance for 42 
approval not less than 30 days before the date on which the contract 43 
is to become effective. 44   
 	– 23 – 
 
 
- 	*AB463* 
 (b) Does not become effective unless approved by the 1 
Commissioner. 2 
 (c) Shall be deemed to be approved if not disapproved by the 3 
Commissioner within 30 days after its submission. 4 
 6.  As used in this section, “legal services organization” means 5 
an organization that operates a program for legal aid and receives 6 
money pursuant to NRS 19.031. 7 
 Sec. 31.  NRS 287.04335 is hereby amended to read as 8 
follows: 9 
 287.04335 If the Board provides health insurance through a 10 
plan of self-insurance, it shall comply with the provisions of NRS 11 
439.581 to 439.597, inclusive, 686A.135, paragraphs (b) and (c) of 12 
subsection 2 of NRS 687B.225, subsections 1, 3 and 5 to 8, 13 
inclusive, of NRS 687B.225, 687B.352, 687B.409, 687B.692, 14 
687B.723, 687B.725, 687B.805, 689B.0353, 689B.255, 695C.1723, 15 
695G.150, 695G.155, 695G.160, 695G.162, 695G.1635, 695G.164, 16 
695G.1645, 695G.1665, 695G.167, 695G.1675, 695G.170 to 17 
695G.1712, inclusive, 695G.1714 to 695G.174, inclusive, 18 
695G.176, 695G.177, 695G.200 to 695G.230, inclusive, 695G.241 19 
to 695G.310, inclusive, 695G.405 and 695G.415, and sections 2 to 20 
26, inclusive, of this act in the same manner as an insurer that is 21 
licensed pursuant to title 57 of NRS is required to comply with those 22 
provisions. 23 
 Sec. 32.  Chapter 422 of NRS is hereby amended by adding 24 
thereto the provisions set forth as sections 33 to 54, inclusive, of this 25 
act. 26 
 Sec. 33.  1. The provisions of sections 34 to 54, inclusive, of 27 
this act and any policies developed pursuant thereto do not apply 28 
to the delivery of services to recipients of Medicaid or the 29 
Children’s Health Insurance Program through managed care in 30 
accordance with NRS 422.273. 31 
 2. A health maintenance organization or other managed care 32 
organization that enters into a contract with the Department or the 33 
Division pursuant to NRS 422.273 to provide health care services 34 
to recipients of Medicaid under the State Plan for Medicaid or the 35 
Children’s Health Insurance Program shall comply with NRS 36 
687B.225 and sections 2 to 26, inclusive, of this act. 37 
 Sec. 34.  As used in sections 34 to 54, inclusive, of this act, 38 
unless the context otherwise requires, the words and terms defined 39 
in sections 35 to 43, inclusive, of this act have the meanings 40 
ascribed to them in those sections. 41 
 Sec. 35.  “Adverse determination”:  42 
 1. Means a determination by the Department that the medical 43 
care or dental care furnished or proposed to be furnished to a 44 
recipient is not medically necessary, or is experimental or 45   
 	– 24 – 
 
 
- 	*AB463* 
investigational, and the requested care or payment for the care is 1 
therefore denied, reduced or terminated. 2 
 2. Does not include the denial, reduction or termination of 3 
coverage or payment for medical care or dental care for a reason 4 
other than the medical necessity or experimental or investigational 5 
nature of the medical care or dental care at issue in a request for 6 
prior authorization, including, without limitation, the denial of 7 
coverage for medical care or dental care that is not covered under 8 
Medicaid or the Children’s Health Insurance Program. 9 
 Sec. 36.  “Approval” means a determination by the 10 
Department that the medical care or dental care furnished or 11 
proposed to be furnished to a recipient has been reviewed and, 12 
based on the information provided to the Department, satisfies the 13 
Department’s criteria for medical necessity or appropriateness and 14 
the requested care or payment for the care is therefore approved. 15 
 Sec. 37.  “Emergency services” means health care services 16 
that are provided in a medical facility by a provider of health care 17 
to screen and to stabilize a recipient after the sudden onset of a 18 
medical condition that manifests itself by symptoms of such 19 
sufficient severity that a prudent layperson, who possesses average 20 
knowledge of health and medicine, would believe that the absence 21 
of immediate medical attention could result in: 22 
 1. Placing the health of the recipient in serious jeopardy; 23 
 2. Placing the health of an unborn child of the recipient in 24 
serious jeopardy; 25 
 3. A serious impairment of a bodily function of the recipient; 26 
or 27 
 4. A serious dysfunction of any bodily organ or part of the 28 
recipient. 29 
 Sec. 38.  “Individually identifiable health information” 30 
means information relating to the provision of medical or dental 31 
care to a recipient: 32 
 1. That specifically identifies the recipient; or 33 
 2. For which there is a reasonable basis to believe that the 34 
information can be used to identify the recipient. 35 
 Sec. 39.  “Medical facility” has the meaning ascribed to it in 36 
NRS 449.0151. 37 
 Sec. 40.  “Medically necessary” has the meaning ascribed to 38 
it in NRS 695G.055. 39 
 Sec. 41.  “Provider of health care” has the meaning ascribed 40 
to it in NRS 695G.070. 41 
 Sec. 42.  “Recipient” means a natural person who receives 42 
benefits through Medicaid or the Children’s Health Insurance 43 
Program, as applicable. 44 
 Sec. 43.  “Urgent health care”: 45   
 	– 25 – 
 
 
- 	*AB463* 
 1. Means health care, including, without limitation, mental 1 
and behavioral health care that, in the opinion of a provider of 2 
health care with knowledge of a recipient’s medical condition, if 3 
not rendered to the recipient within 48 hours could: 4 
 (a) Seriously jeopardize the life or health of the recipient or 5 
the ability of the recipient to regain maximum function; or 6 
 (b) Subject the recipient to severe pain that cannot be 7 
adequately managed without receiving such care. 8 
 2. Does not include emergency services. 9 
 Sec. 44.  1. The Department, with respect to Medicaid and 10 
the Children’s Health Insurance Program, shall establish written 11 
procedures for obtaining prior authorization for medical or dental 12 
care which must include, without limitation: 13 
 (a) Specific goods and services for which the Department 14 
requires prior authorization; and 15 
 (b) Clinical review criteria used by the Department. 16 
 2. The Department shall publish the written procedures for 17 
obtaining prior authorization established by the Department 18 
pursuant to subsection 1, including, without limitation, the clinical 19 
review criteria, on an Internet website maintained by the 20 
Department: 21 
 (a) Using clear language that is understandable to an ordinary 22 
layperson, where practicable; and 23 
 (b) In a place that is readily accessible and conspicuous to 24 
recipients and the public. 25 
 3. If the Department amends the procedure for obtaining 26 
prior authorization established pursuant to subsection 1, 27 
including, without limitation, changing the goods and services for 28 
which the Department requires prior authorization or changing 29 
the clinical review criteria used by the Department, the 30 
Department shall: 31 
 (a) Transmit a notice containing a summary of the changes 32 
made to the procedure to each recipient and each provider of 33 
goods or services under Medicaid or the Children’s Health 34 
Insurance Program, as applicable; and 35 
 (b) Update the information published on its Internet website 36 
pursuant to subsection 2 to reflect the amended procedure for 37 
obtaining prior authorization and the date on which the amended 38 
procedure takes effect. 39 
 4. A change to the Department’s procedure for obtaining 40 
prior authorization may not take effect until 60 days have passed 41 
after the later of: 42 
 (a) The date on which the Department transmitted the notice to 43 
recipients and providers of goods or services under Medicaid or 44   
 	– 26 – 
 
 
- 	*AB463* 
the Children’s Health Insurance Program, as applicable, pursuant 1 
to paragraph (a) of subsection 3; or 2 
 (b) The date on which the Department updated the 3 
information published on its Internet website pursuant to 4 
paragraph (b) of subsection 3. 5 
 5. The Department shall not deny a claim based on the 6 
failure of a recipient to obtain prior authorization for medical or 7 
dental care if the procedure for obtaining prior authorization 8 
established by the Department pursuant to this section did not 9 
require the recipient to obtain prior authorization for that medical 10 
or dental care on the date on which the medical or dental care was 11 
provided to the recipient. 12 
 6. As used in this section, “clinical review criteria” means 13 
any written screening procedure, formulary decision abstract, 14 
clinical protocol, practice guideline or other criteria used by the 15 
Department to determine the necessity and appropriateness of 16 
medical or dental care. 17 
 Sec. 45.  1. Unless a shorter time period is prescribed by a 18 
specific statute, and except as otherwise provided in subsection 2, 19 
the Department, with respect to Medicaid and the Children’s 20 
Health Insurance Program, shall approve or deny a request for 21 
prior authorization submitted by or on behalf of a recipient and 22 
notify the recipient and his or her provider of health care of the 23 
approval or denial: 24 
 (a) For non-urgent medical or dental care, within 48 hours 25 
after receiving the request. 26 
 (b) For urgent health care, within 24 hours after receiving the 27 
request. 28 
 2. If the Department requires additional, medically relevant 29 
information or documentation in order to adequately evaluate a 30 
request for prior authorization, the Department shall: 31 
 (a) Notify the recipient and the provider of health care who 32 
submitted the request within the applicable amount of time 33 
described in subsection 1 that additional information is required to 34 
evaluate the request; 35 
 (b) Include within the notification sent pursuant to paragraph 36 
(a) a description, with reasonable specificity, of the information 37 
that the Department requires to make a determination on the 38 
request for prior authorization; and 39 
 (c) Approve or deny the request: 40 
  (1) For non-urgent medical or dental care, within 48 hours 41 
after receiving the information. 42 
  (2) For urgent health care, within 24 hours after receiving 43 
the information. 44   
 	– 27 – 
 
 
- 	*AB463* 
 Sec. 46.  1. The Department, with respect to Medicaid and 1 
the Children’s Health Insurance Program, shall not make an 2 
adverse determination on a request for prior authorization unless 3 
the adverse determination is made by a physician licensed 4 
pursuant to chapter 630 or 633 of NRS or, for dental care, a 5 
dentist licensed in this State who: 6 
 (a) Is of the same or similar specialty as a physician or dentist, 7 
as applicable, who typically manages or treats the medical or 8 
dental condition or provides the medical or dental care involved in 9 
the request; and 10 
 (b) Has experience treating or managing the medical or dental 11 
condition involved in the request. 12 
 2. If a physician or dentist described in subsection 1 is 13 
considering making an adverse determination on a request for 14 
prior authorization on the basis that the medical or dental care 15 
involved in the request is not medically necessary, the Department 16 
shall: 17 
 (a) Immediately notify the provider of health care who 18 
submitted the request that the medical necessity of the requested 19 
care is being questioned by the Department; and 20 
 (b) Offer the provider of health care an opportunity to speak 21 
with the physician or dentist, as applicable, over the telephone or 22 
by videoconference to discuss the clinical issues involved in the 23 
request before the physician or dentist renders an initial 24 
determination on the request. 25 
 3. Upon rendering an adverse determination on a request for 26 
prior authorization, the Department shall immediately transmit to 27 
the recipient to whom the request pertains a written notice that 28 
contains: 29 
 (a) A specific description of all reasons that the Department 30 
made the adverse determination; 31 
 (b) A description of any documentation that the Department 32 
requested from the recipient or a provider of health care of the 33 
recipient and did not receive or deemed insufficient, if the failure 34 
to receive sufficient documentation contributed to the adverse 35 
determination; 36 
 (c) A statement that the recipient has the right to appeal the 37 
adverse determination; 38 
 (d) Instructions, written in clear language that is 39 
understandable to an ordinary layperson, describing how the 40 
recipient can appeal the adverse determination through the 41 
process established pursuant to subsection 4; and 42 
 (e) A description of any documentation that may be necessary 43 
or pertinent to a potential appeal. 44   
 	– 28 – 
 
 
- 	*AB463* 
 4. The Department shall establish a process that allows a 1 
recipient to appeal an adverse determination on a request for prior 2 
authorization. The process must allow for the clear resolution of 3 
each appeal within a reasonable time. 4 
 5. The Department shall not uphold on appeal an adverse 5 
determination pertaining to a request for prior authorization 6 
unless the decision on the appeal is made by a physician licensed 7 
pursuant to chapter 630 or 633 of NRS or, for dental care, a 8 
dentist licensed in this State who: 9 
 (a) Is actively practicing medicine or dentistry, as applicable, 10 
within the same or similar specialty as a physician or dentist, as 11 
applicable, who typically manages or treats the medical or dental 12 
condition or provides the medical or dental care involved in the 13 
request and has been actively practicing in that specialty for at 14 
least 5 consecutive years preceding the date on which the 15 
physician or dentist, as applicable, makes the determination on the 16 
appeal; 17 
 (b) Is knowledgeable of and has experience treating or 18 
managing the medical or dental condition involved in the request; 19 
 (c) Was not involved in making the adverse determination that 20 
is the subject of the appeal; 21 
 (d) Has no financial interest in the outcome of the request for 22 
prior authorization that is the subject of the appeal; 23 
 (e) Is not employed by or contracted with the Department or 24 
any administrator contracted by the Department except: 25 
  (1) To participate in Medicaid as a provider of services; 26 
  (2) To make determinations on appeals of adverse 27 
determinations; or 28 
  (3) For the purposes described in both subparagraphs (1) 29 
and (2); and 30 
 (f) Considers all known clinical aspects of the medical or 31 
dental care involved in the request, including, without limitation: 32 
  (1) The medical records of the recipient that are provided 33 
or accessible to the Department, including those records provided 34 
to the Department by the recipient or a provider of health care of 35 
the recipient; 36 
  (2) The clinical review criteria adopted by the Department 37 
pursuant to section 44 of this act; and 38 
  (3) Medical or scientific evidence provided to the 39 
Department by the provider of health care who requested prior 40 
authorization for the care at issue. 41 
 6. As used in this section: 42 
 (a) “Administrator” has the meaning ascribed to it in  43 
NRS 683A.025. 44   
 	– 29 – 
 
 
- 	*AB463* 
 (b) “Medical or scientific evidence” has the meaning ascribed 1 
to it in NRS 695G.053. 2 
 Sec. 47.  1. Except as otherwise provided in subsection 2, if 3 
the Department approves a request for prior authorization, the 4 
approval remains valid until the later of: 5 
 (a) Twelve months after the date on which the request is 6 
approved; or 7 
 (b) If the approval relates to the treatment of a chronic 8 
condition, until the standard of treatment for that condition 9 
changes. 10 
 2. If the Department has previously granted prior 11 
authorization for a course of care or regimen for prescription 12 
drugs ordered or prescribed for a recipient, the Department shall 13 
not require the recipient to obtain additional prior authorization 14 
for the course of care or regimen for prescription drugs previously 15 
approved by the Department. 16 
 3. The Department shall not revoke or impose an additional 17 
limit, condition or restriction on a request for prior authorization 18 
that the Department has previously approved unless: 19 
 (a) The care at issue in the request was not provided to the 20 
recipient within 45 business days after the date on which the 21 
Department received the request; 22 
 (b) The Department determines that a recipient or a provider 23 
of health care procured the approval by fraud or material 24 
misrepresentation; or 25 
 (c) The Department determines that the care at issue in the 26 
request was not covered by Medicaid or the Children’s Health 27 
Insurance Program, as applicable, at the time the care was 28 
provided. 29 
 4. If the Department approves a request for prior 30 
authorization, the Department shall promptly pay a provider of 31 
health care for a claim for the approved medical or dental care at 32 
the full rate of reimbursement provided under Medicaid or the 33 
Children’s Health Insurance Program, as applicable, unless: 34 
 (a) The provider of health care knowingly and materially 35 
misrepresented the medical care or dental care contained in the 36 
request with the specific intent to deceive and obtain a payment 37 
from the health carrier to which the provider of health care was 38 
not entitled; 39 
 (b) The provider of health care was not a participating 40 
provider of services under Medicaid or the Children’s Health 41 
Insurance Program, as applicable, on the date that the care was 42 
provided; 43 
 (c) The claim for the medical or dental care was not timely 44 
submitted in accordance with the applicable terms and conditions 45   
 	– 30 – 
 
 
- 	*AB463* 
of Medicaid or the Children’s Health Insurance Program, as 1 
applicable; or 2 
 (d) Any of the criteria described in subsection 2 of section 52 3 
of this act is applicable to the particular claim. 4 
 5. Within the first 90 days that a recipient is enrolled in 5 
Medicaid or the Children’s Health Insurance Program, as 6 
applicable, the Department shall honor a request for prior 7 
authorization that has been approved by a health carrier or other 8 
entity that previously provided the recipient with coverage for 9 
medical or dental care if: 10 
 (a) The approval was issued within the 12 months immediately 11 
preceding the first day of the enrollment of the recipient; and 12 
 (b) The specific medical or dental care included within the 13 
request is not affirmatively excluded under the terms and 14 
conditions of Medicaid or the Children’s Health Insurance 15 
Program, as applicable. 16 
 6. The Department may undertake an independent review of 17 
the care approved by the previous health carrier of a recipient 18 
which is subject to the requirements of subsection 5 for the 19 
purpose of granting its own approval of the care. The Department 20 
may not deny approval in violation of subsection 5 as the result of 21 
such a review. 22 
 7. As used in this section: 23 
 (a) “Chronic condition” means a condition that is expected to 24 
last 1 year or more and: 25 
  (1) Requires ongoing medical attention to effectively 26 
manage the condition or prevent an event that adversely affects 27 
the health of the person; or 28 
  (2) Limits one or more activities of daily living. 29 
 (b) “Health carrier” has the meaning ascribed to it in NRS 30 
695G.024 and includes, without limitation, an organization for 31 
dental care. 32 
 Sec. 48.  1. The Department, with respect to Medicaid and 33 
the Children’s Health Insurance Program, shall not require prior 34 
authorization for: 35 
 (a) Outpatient services for the treatment of a mental health 36 
condition or substance use disorder. 37 
 (b) Antineoplastic treatment for cancer, other than 38 
prescription drugs, that is consistent with the guidelines 39 
established by the National Comprehensive Cancer Network, or its 40 
successor organization. 41 
 (c) Evidence-based goods or services for preventive care that 42 
have in effect a grade of “A” or “B” identified by the United 43 
States Preventive Services Task Force. 44   
 	– 31 – 
 
 
- 	*AB463* 
 (d) Preventive care for women described in 45 C.F.R. § 1 
147.130(a)(iv). 2 
 (e) Hospice care provided to pediatric patients in a facility for 3 
hospice care licensed pursuant to chapter 449 of NRS. 4 
 (f) Care provided to treat neonatal abstinence syndrome 5 
provided by a provider of health care who specializes in pain 6 
management for pediatric patients or palliative care provided to 7 
pediatric patients. 8 
 2. As used in this section: 9 
 (a) “Facility for hospice care” has the meaning ascribed to it 10 
in NRS 449.0033. 11 
 (b) “Hospice care” has the meaning ascribed to it in  12 
NRS 449.0115. 13 
 Sec. 49.  1.  The Department, with respect to Medicaid and 14 
the Children’s Health Insurance Program, shall not require prior 15 
authorization for covered emergency services, including, where 16 
applicable, transportation by ambulance to a hospital or other 17 
medical facility. 18 
 2. If the Department requires a recipient or his or her 19 
provider of health care to notify the Department that the recipient 20 
has been admitted to a hospital to receive emergency services or 21 
has received emergency services, the Department shall not require 22 
a recipient or a provider of health care to transmit such a notice 23 
earlier than the end of the business day immediately following the 24 
date on which the recipient was admitted or the emergency 25 
services were provided, as applicable. 26 
 3. The Department shall not deny coverage for emergency 27 
services covered by Medicaid or the Children’s Health Insurance 28 
Program that are medically necessary. Emergency services are 29 
presumed to be medically necessary if, within 72 hours after a 30 
recipient is admitted to receive emergency services, the provider of 31 
health care of the recipient transmits to the Department a 32 
certification, in writing, that the condition of the recipient 33 
required emergency services. The Department may rebut that 34 
presumption by establishing, by clear and convincing evidence, 35 
that the emergency services were not medically necessary. 36 
 4. If a recipient receives emergency services and must 37 
additionally receive post-evaluation or post-stabilization medical 38 
care, and the Department requires prior authorization for the post-39 
evaluation or post-stabilization care, the Department shall approve 40 
or deny a request for prior authorization for such care within 60 41 
minutes after receiving the request. 42 
 Sec. 50.  1. The Department shall exempt a provider of 43 
health care from the requirement to obtain prior authorization for 44 
a specific good or service if, within the immediately preceding 12 45   
 	– 32 – 
 
 
- 	*AB463* 
months, the Department approved 80 percent or more of the 1 
requests for prior authorization for that specific good or service 2 
submitted by the provider of health care. If a provider of health 3 
care qualifies for an exemption pursuant to this section, the 4 
Department shall: 5 
 (a) Automatically grant the exemption without requiring the 6 
provider of health care to submit a request for the exemption; and 7 
 (b) Transmit to the provider of health care after granting the 8 
exemption a notice that includes: 9 
  (1) A statement that the provider of health care has been 10 
granted an exemption from the requirement to obtain prior 11 
authorization from the Department for the specific goods and 12 
services listed pursuant to subparagraph (2); 13 
  (2) A list of goods and services to which the exemption 14 
applies; and 15 
  (3) The date on which the exemption expires, which must 16 
not be earlier than 12 months after the date on which the 17 
Department granted the exemption. 18 
 2. The Department shall provide for an annual review of all 19 
of the requests for prior authorization submitted by providers of 20 
health care during the immediately preceding year to determine 21 
whether those providers meet the criteria prescribed by subsection 22 
1 for an exemption from the requirement to obtain prior 23 
authorization. If a provider of health care is initially determined to 24 
be ineligible for an exemption based on such a review, the 25 
eligibility of the provider of health care to receive an exemption 26 
must be independently determined by a provider of health care 27 
who: 28 
 (a) Is licensed in this State; 29 
 (b) Is of the same or similar specialty as the provider of health 30 
care who is being evaluated for an exemption; and 31 
 (c) Has experience providing the good or service for which the 32 
exemption has been initially denied. 33 
 3. A provider of health care who is not granted an exemption 34 
from the requirement to obtain prior authorization for a particular 35 
good or service may, for that specific good or service, request from 36 
the Department any evidence that supported the decision of the 37 
Department to not grant the exemption for that good or service. A 38 
provider of health care may submit a request for supporting 39 
evidence pursuant to this subsection not more than once during a 40 
single 12-month period for each good or service for which the 41 
provider of health care has not been granted an exemption. 42 
 4. An exemption from the requirement to obtain prior 43 
authorization pursuant to this section applies to the provision of 44 
any good or service covered by the exemption which is provided or 45   
 	– 33 – 
 
 
- 	*AB463* 
ordered by the provider of health care to whom the exception 1 
applies. 2 
 5. The Department shall not deny a claim or reduce the 3 
amount of payment paid under a claim for a good or service that is 4 
subject to an exemption pursuant to this section unless: 5 
 (a) The provider of health care who submitted the claim 6 
knowingly and materially misrepresented the goods or services 7 
actually provided to a recipient, and the provider of health care 8 
made the misrepresentation with the specific intent to obtain a 9 
payment from the Department to which the provider of health care 10 
is not legally or contractually entitled; or 11 
 (b) The service or good for which payment is sought was not 12 
substantially performed or provided, as applicable. 13 
 Sec. 51.  1. Not more than once during a single 12-month 14 
period, the Department may reevaluate the eligibility of a provider 15 
of health care to receive an exemption from the requirement to 16 
obtain prior authorization pursuant to section 50 of this act. 17 
 2. The Department may, pursuant to subsection 1, revoke an 18 
exemption from the requirement to obtain prior authorization 19 
granted to a provider of health care only if the Department 20 
determines that the provider of health care would not have met the 21 
criteria prescribed in subsection 1 of section 50 of this act for the 22 
good or service to which the exemption applies based on: 23 
 (a) A retrospective review of claims submitted by the provider 24 
of health care for that good or service during the immediately 25 
preceding 3 months; or 26 
 (b) If the provider of health care did not submit at least 10 27 
claims for that good or service during the immediately preceding 3 28 
months, a retrospective review of at least the last 10 claims 29 
submitted by the provider of health care for that good or service. 30 
 3. If it is initially determined that a provider of health care 31 
meets the criteria prescribed in subsection 2 for the revocation of 32 
an exemption based on a review conducted pursuant to that 33 
subsection, the satisfaction of those criteria must be independently 34 
determined by a provider of health care described in subsection 2 35 
of section 50 of this act before the Department may revoke the 36 
exemption. 37 
 4. If the Department revokes an exemption from the 38 
requirement to obtain prior authorization pursuant to subsection 39 
2, the Department shall transmit to the provider of health care to 40 
which the revocation pertains a notice to that includes: 41 
 (a) The information that the Department relied upon when 42 
making the determination described in subsection 2; 43 
 (b) An identification of each good or service to which the 44 
revoked exemption applies; 45   
 	– 34 – 
 
 
- 	*AB463* 
 (c) The date on which the revocation takes effect, which must 1 
not be earlier than 30 days after the date on which the Department 2 
transmits the notice; and 3 
 (d) A description, written in easily comprehensible language, 4 
of how the provider of health care may appeal the revocation 5 
pursuant to subsection 5. 6 
 5. The Department shall adopt a procedure by which a 7 
provider of health care may appeal the revocation of an exemption 8 
from the requirement to obtain prior authorization. If a provider 9 
of health care appeals a revocation of such exemption, the 10 
exemption must remain in effect: 11 
 (a) If the revocation is reversed on appeal, until the next 12 
reevaluation pursuant to subsection 1 of the eligibility of the 13 
provider of health care to continue receiving the exemption. 14 
 (b) If the revocation is upheld on appeal, until the later of the 15 
5th calendar day after the revocation is upheld or the date 16 
contained within the notice sent to the provider of health care 17 
pursuant to subsection 4. 18 
 Sec. 52.  1. If the Department violates sections 44 to 51, 19 
inclusive, of this act with respect to a particular request for prior 20 
authorization, the request shall be deemed approved.  21 
 2. Nothing in sections 44 to 51, inclusive, of this act shall be 22 
construed to require the Department to provide coverage: 23 
 (a) For medical or dental care that, regardless of whether such 24 
care is medically necessary, would not be a covered benefit under 25 
the terms and conditions of Medicaid or the Children’s Health 26 
Insurance Program, as applicable; or 27 
 (b) To a person who is not a recipient or is not otherwise 28 
eligible to receive coverage under Medicaid or the Children’s 29 
Health Insurance Program, as applicable, on the date on which 30 
medical or dental care is provided to the person. 31 
 Sec. 53.  1. On or before March 1 of each calendar year, the 32 
Department shall publish on an Internet website maintained by 33 
the Department in an easily accessible format the following 34 
information for the immediately preceding calendar year, in 35 
aggregated form for all requests for prior authorization received 36 
by the Department during the immediately preceding year and 37 
disaggregated in accordance with subsection 2: 38 
 (a) The percentage of requests for prior authorization for 39 
medical or dental care that were approved upon initial review; 40 
 (b) The percentage of requests for prior authorization for 41 
medical or dental care that resulted in an adverse determination 42 
upon initial review; 43 
 (c) The percentage of the adverse determinations described in 44 
paragraph (b) that were appealed; 45   
 	– 35 – 
 
 
- 	*AB463* 
 (d) The percentage of appeals of adverse determinations 1 
described in paragraph (c) that resulted in a reversal of the 2 
adverse determination; 3 
 (e) The five most common reasons for the adverse 4 
determinations described in paragraph (b); and 5 
 (f) The average time between a request for prior authorization 6 
for medical or dental care in this State and the resolution of the 7 
request. 8 
 2. The information described in subsection 1 must be 9 
disaggregated for the following categories: 10 
 (a) The specialty of the provider of health care who submitted 11 
a request for prior authorization; and 12 
 (b) The types of medical or dental care at issue in the request 13 
for prior authorization, including the specific types of prescription 14 
drugs, procedures or diagnostic tests involved in the requests. 15 
 3. The Department shall not include individually identifiable 16 
health information in the information published pursuant to 17 
subsection 1. 18 
 Sec. 54.  1. On or before March 1 of each calendar year, the 19 
Department shall: 20 
 (a) Compile a report containing the following information for 21 
Medicaid and the Children’s Health Insurance Program: 22 
  (1) The specific goods and services for which the 23 
Department requires prior authorization and, for each good or 24 
service: 25 
   (I) The date on which the Department began requiring 26 
prior authorization for that good or service and the date on which 27 
that requirement was listed on the Internet website of the 28 
Department pursuant to section 44 of this act;  29 
   (II) The number of requests for prior authorization 30 
received by the Department during the immediately preceding 31 
calendar year for the provision of the good or service; 32 
   (III) The number and percentage of the requests listed 33 
pursuant to sub-subparagraph (II) that were approved; 34 
   (IV) The number and percentage of the requests listed 35 
pursuant to sub-subparagraph (II) that resulted in adverse 36 
determinations; and 37 
   (V) The number of appeals from adverse determinations 38 
during the immediately preceding calendar year and the 39 
percentage of those appeals that were reversed on appeal by the 40 
Department; 41 
  (2) The information described in sub-subparagraphs (II) to 42 
(V), inclusive, aggregated for all requests for prior authorization 43 
received by the Department during the immediately preceding 44 
calendar year; 45   
 	– 36 – 
 
 
- 	*AB463* 
  (3) A list of each reason that the Department issued an 1 
adverse determination on a request for prior authorization during 2 
the immediately preceding calendar year, and the percentage for 3 
which each reason listed accounts for all adverse determinations 4 
issued by the Department during the immediately preceding 5 
calendar year; 6 
  (4) For all requests for prior authorization for non-urgent 7 
health or dental care received by the Department during the 8 
immediately preceding calendar year, the average and median 9 
time between: 10 
   (I) The Department receiving a request for prior 11 
authorization and the Department approving or making an 12 
adverse determination on the request; and 13 
   (II) The submission of an appeal of an adverse 14 
determination on a request for prior authorization and the 15 
resolution of the appeal; and 16 
  (5) For all requests for prior authorization for urgent 17 
health care received by the Department during the immediately 18 
preceding calendar year, the average and median time between: 19 
   (I) The Department receiving a request for prior 20 
authorization and the Department approving or making an 21 
adverse determination on the request; and 22 
   (II) The submission of an appeal of an adverse 23 
determination on a request for prior authorization and the 24 
resolution of the appeal; 25 
 (b) Post the report on the Internet website maintained by the 26 
Department; and 27 
 (c) Submit the report to the Director of the Legislative Counsel 28 
Bureau for transmittal to the Joint Interim Standing Committee 29 
on Health and Human Services. 30 
 2. The Department shall not include individually identifiable 31 
health information in a report published pursuant to subsection 1. 32 
 Sec. 55.  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 
34 to 54, inclusive, of this act for use by the Medicaid program for 43 
prescription drugs; and 44   
 	– 37 – 
 
 
- 	*AB463* 
 (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 accept and respond to any request 30 
for prior authorization for a prescription drug through a secure 31 
electronic transmission using the National Council for 32 
Prescription Drug Programs SCRIPT standard described in 42 33 
C.F.R. § 423.160(b). 34 
 5. The procedures for prior authorization established 35 
pursuant to this section must not apply to prescription drugs 36 
ordered as a part of a course of medication-assisted treatment for 37 
opioid use disorder. 38 
 6. The Department shall not require the Drug Use Review 39 
Board to develop, review or approve prior authorization policies or 40 
procedures necessary for the operation of the list of preferred 41 
prescription drugs developed pursuant to NRS 422.4025. 42 
 [5.] 7.  The Department shall accept recommendations from the 43 
Drug Use Review Board as the basis for developing or revising step 44   
 	– 38 – 
 
 
- 	*AB463* 
therapy protocols and prior authorization policies and procedures 1 
used by the Medicaid program for prescription drugs. 2 
 [6.] 8. As used in this section: 3 
 (a) “Medical or scientific evidence” has the meaning ascribed to 4 
it in NRS 695G.053. 5 
 (b) “Prior authorization” includes any requirement that 6 
requires a recipient of Medicaid to notify the Department before 7 
receiving medical care. 8 
 (c) “Step therapy protocol” means a procedure that requires a 9 
recipient of Medicaid to use a prescription drug or sequence of 10 
prescription drugs other than a drug that a practitioner recommends 11 
for treatment of a psychiatric condition of the recipient before 12 
Medicaid provides coverage for the recommended drug. 13 
 Sec. 56.  NRS 608.1555 is hereby amended to read as follows: 14 
 608.1555 Any employer who provides benefits for health care 15 
to his or her employees shall provide the same benefits and pay 16 
providers of health care in the same manner as a policy of insurance 17 
pursuant to chapters 689A and 689B of NRS, including, without 18 
limitation, as required by paragraphs (b) and (c) of subsection 2 of 19 
NRS 687B.225, subsections 1, 3 and 5 to 8, inclusive, of NRS 20 
687B.225, NRS 687B.409, 687B.723 and 687B.725 [.] and sections 21 
2 to 26, inclusive, of this act. 22 
 Sec. 57.  1.  The amendatory provisions of this act do not 23 
apply to a request for prior authorization submitted: 24 
 (a) Under a contract or policy of health insurance issued before 25 
January 1, 2026, but apply to any request for prior authorization 26 
submitted under any renewal of such a contract or policy. 27 
 (b) To the Department of Health and Human Services before 28 
January 1, 2026, for medical or dental care provided to a recipient of 29 
Medicaid. 30 
 2. A health carrier must, in order to continue requiring prior 31 
authorization in contracts or policies of health insurance issued or 32 
renewed after January 1, 2026: 33 
 (a) Develop a procedure for obtaining prior authorization that 34 
complies with NRS 687B.225, as amended by section 27 of this act, 35 
and sections 2 to 26, inclusive, of this act; and 36 
 (b) Obtain the approval of the Commissioner of Insurance 37 
pursuant to NRS 687B.225, as amended by section 27 of this act, for 38 
the procedure developed pursuant to paragraph (a). 39 
 3. As used in this section, “health carrier” has the meaning 40 
ascribed to it in section 7 of this act. 41 
 Sec. 58.  The provisions of subsection 1 of NRS 218D.380 do 42 
not apply to any provision of this act which adds or revises a 43 
requirement to submit a report to the Legislature. 44   
 	– 39 – 
 
 
- 	*AB463* 
 Sec. 59.  The provisions of NRS 354.599 do not apply to any 1 
additional expenses of a local government that are related to the 2 
provisions of this act. 3 
 Sec. 60.  1. This section and section 57 of this act become 4 
effective upon passage and approval. 5 
 2. Sections 1 to 56, inclusive, 58 and 59 of this act become 6 
effective: 7 
 (a) Upon passage and approval for the purposes of adopting any 8 
regulations, performing any other preparatory administrative tasks 9 
that are necessary to carry out the provisions of this act and 10 
approving procedures for obtaining prior authorization pursuant to 11 
NRS 687B.225, as amended by section 27 of this act, and section 57 12 
of this act; and 13 
 (b) On January 1, 2026, for all other purposes. 14 
 
H