Nevada lets the physician file the review in their own name

The venue is not the insurance department

Except for an expedited request, all requests for external review must be made in writing to the Office for Consumer Health Assistance. The Division of Insurance approves the independent review organizations that may be assigned, but the request itself is filed with the consumer-health office — which is the first thing to get right, because a request sent to the wrong body is not a request that has been filed.

Thirty days of silence ends the internal appeal

Nevada does not leave a stalled grievance open-ended. If the covered person or their authorized representative does not receive a written decision from the health carrier within 30 days after filing a grievance under the internal grievance process, they may file a request for external review and are considered to have exhausted the carrier's internal grievance process. Silence converts into a right to escalate.

A short review, in three steps

Once a request reaches an independent review organization, the sequence is tight and each step has its own clock:

• Within 5 days of receiving the request, the organization reviews it and the documents submitted, and notifies the covered person, the physician and the health carrier if further information is required.
• Any additional information is to be provided within 5 days after receiving that notice.
• The organization approves, modifies or reverses the adverse determination within 15 days after it receives the information required to make the determination.

The carrier has to tell you this exists

The obligation is on the insurer, and it is specific. A health carrier must notify the covered person in writing of the right to request an external review under Chapter 695G, and must include the appropriate statements and information at the same time it sends written notice of an adverse determination on completion of its utilization review process. That notice is where the plan's own instructions and timing appear.

Four months, and the physician's own clock

NRS 695G.251(1) is unusually direct about who holds the right. Where a covered person OR a physician of a covered person receives notice of an adverse determination, the covered person, the physician of the covered person or an authorized representative may, within four months after receiving notice of that determination, submit a request to the Office for Consumer Health Assistance for an external review. The physician is named twice — as someone who receives the notice, and as someone who may file.

• Filing window: 4 months after receiving notice of the adverse determination.
• Who may file: the covered person, the physician of the covered person, or an authorized representative.
• Where: the Office for Consumer Health Assistance, in writing (expedited requests excepted).
• Within 5 days of receiving the request, that Office notifies the covered person, the physician, the carrier's utilization review agent if any, and the carrier that it has been filed.

Who may be assigned

An independent review organization must be approved by the Division of Insurance before it can be assigned to conduct external reviews in Nevada. Approval by the regulator, and assignment through the consumer-health office, keeps the choice of reviewer away from both the carrier and the patient.

For Nevada practices

Log the date the internal grievance was filed, because at day 30 without a written decision it becomes the basis for escalating. Address the request to the Office for Consumer Health Assistance in writing. And assemble the file completely before sending: with a 15-day decision clock that only starts once the reviewer has what it needs, a complete submission is worth more here than in states where the reviewer has 45 days to catch up.

No registration, no utilization review

Nevada regulates the reviewer as an entity, not merely as a step in a process. Under NRS 683A.375 to 683A.379, no person may conduct utilization review in the state unless registered with the Commissioner as an agent who performs utilization review, and that agent must have a medical director who is a physician — or a dentist, where the agent reviews dental services — licensed in a state.

Nevada also fixes when the next step is disclosed. The carrier must give written notice of the right to external review at the same time it issues the adverse determination, so the escalation route is not something a practice has to discover after the fact.