Nev. Admin. Code § 287.660 - Notification of adverse determination; grounds for appeal

1. The Claims Administrator shall notify a participant of an adverse determination of a claim of the participant or his or her dependent. Such notification must:

(a) Be in writing;

(b) Explain the reason for the adverse determination;

(c) Include the specific provision of the applicable plan of the Program used by the Claims Administrator as the basis for the adverse determination;

(d) If the adverse determination is made as a result of a lack of information, request any additional information necessary to reverse the adverse determination; and

(e) Explain the process for initiating an appeal of the adverse determination pursuant to NAC 287.670.

2. A participant may appeal an adverse determination if the participant feels the claim was not adjudicated pursuant to the current terms and conditions of the Program.

Notes

Nev. Admin. Code § 287.660

Added to NAC by Com. on Group Ins., eff. 3-9-88; A by Bd. of Pub. Employees' Benefits Prog. by R126-00, 12-22-2000, eff. 1-1-2001; R016-08, 8-26-2008, eff. 7-1-2009; R002-12, 6-29-2012

NRS 287.043