Section 687B.360 - Filing and contents of proposed plan of operationA Medicare select issuer shall file a proposed plan of operation with the Commissioner which must include:
1. Evidence that all services covered under the policy that are subject to a provision for a restricted network are available and accessible through network providers, including evidence that: (a) Such services are available from network providers with reasonable promptness with respect to geographic location, hours of operation during regular business hours and hours of operation after regular business hours. The reasonableness of hours of operation and availability must be based on the usual practice in the local area. The reasonableness of the geographic location must be based on average travel times within the community.(b) The number of network providers in the service area is sufficient in relation to the number of current and expected policyholders and certificate holders to: (1) Deliver adequately services that are subject to a provision for a restricted network; or(2) Make appropriate referrals.(c) The Medicare select issuer has executed written agreements with network providers that describe the specific responsibilities of those providers.(d) Emergency care is available 24 hours a day and 7 days a week.(e) For such services that are provided on a prepaid basis, the Medicare select issuer has executed written agreements with network providers that prohibit such providers from billing or otherwise seeking additional reimbursement or recourse against any policyholder or certificate holder, other than seeking collection of supplemental charges or coinsurance payments that are required under the Medicare select policy or certificate.2. A statement or map providing a clear description of the service area.3. A description of the procedure that will be utilized for addressing grievances.4. A description of the program that will be utilized for quality assurance, including details regarding:(a) The formal organizational structure of the program;(b) The written criteria for selecting, retaining and removing network providers;(c) The procedure for evaluating the quality of care provided by network providers; and(d) The process used for initiating corrective action when warranted.5. A list and description of the network providers, categorized by their specialties.6. Copies of the written information, including the contracts and written agreements executed between the Medicare select issuer and the network providers, proposed to be used by the Medicare select issuer to ensure that all services covered under the policy that are subject to a provision for a restricted network are available and accessible through a network provider.7. Any other information requested by the Commissioner.Nev. Admin. Code § 687B.360
Added to NAC by Comm'r of Insurance, eff. 5-13-96