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Utilization Review Agent 

 

Utilization Review is a system that provides for the review of the allocation of health care resources and services provided to an insured or to any person claiming benefits against a policy of the insured.  The term does not include responding to requests made by an insured for clarification of his or her coverage.

A Utilization Review Agent is any entity that performs such a review except a person acting on behalf of the Federal Government, but only to the extent that the person provides the service for the Federal Government or an agency thereof.

Consumers may obtain a copy of the summary plan for utilization review.  Please make all requests for copies in writing at least 5 business days in advance.  All requests should be sent Attn: Specialty Licensing or emailed directly to Lisa Bard at lbard@doi.nv.gov.

Registration Required

An entity conducting utilization review is required to register with the Nevada Division of Insurance.

Exemptions

The registration requirement does not apply to the following entities if the entity is performing its own utilization review:

An authorized insurer;

A fraternal benefit society certified;

A nonprofit corporation for hospital, medical or dental services;

A health maintenance organization (HMO); or

A dental care organization.

Note:  Any subsidiary or affiliates of these entities, or independent agents performing utilization review for these entities, must be registered as a Utilization Review Agent.

Registration Term

Registration as a Utilization Review Agent is valid for one year.

Registration is renewable on or before March 1 each year.

Fees

All fees paid to the Nevada Division of Insurance are nonrefundable.

Initial Application: $310

This fee includes the $60 Administration and Enforcement fee.

Annual Renewal: $310

This fee includes the $60 Administration and Enforcement fee.

Payments may be made by check, money order, or Electronic Funds Transfer (EFT).  Please make checks and money orders payable to the Nevada Division of Insurance.  Please contact the Accounting Section at ifn@doi.nv.gov to request the required EFT form.

How to Apply

An applicant for registration as a Utilization Review Agent must:

Submit a paper application to the Division’s Carson City Office.

Submit a summary of the plan for utilization review.  This summary must include procedures for appealing determinations made through utilization review.

Remit all applicable fees.

You may print a copy of your license by logging into AgencyEdge portal through Sircon.

Note:  Any material changes in the information above must be reported to the Division within 30 days.

How to Renew

Renewal is due annually on or before March 1.  There is no grace period for the renewal.

A registered entity must:

Submit a paper application to the Division’s Carson City Office.

Submit a summary of the plan for utilization review.  This summary must include procedures for appealing determinations made through utilization review.

Remit all applicable fees.

Legal Authority

Utilization Review Agents are regulated under the provisions of chapter 683A of the Nevada Revised Statutes (NRS) and chapter 683A of the Nevada Administrative Code (NAC).