Nevada Revised Statutes 695C.1755 – Evidence of coverage prohibited from excluding coverage for treatment of temporomandibular joint; exception
1. Except as otherwise provided in this section, no evidence of coverage may be delivered or issued for delivery in this state if it contains an exclusion of coverage of the treatment of the temporomandibular joint whether by specific language in the evidence of coverage or by a claims settlement practice. An evidence of coverage may exclude coverage of those methods of treatment which are recognized as dental procedures, including, but not limited to, the extraction of teeth and the application of orthodontic devices and splints.
Terms Used In Nevada Revised Statutes 695C.1755
- Enrollee: means a natural person who has been voluntarily enrolled in a health care plan. See Nevada Revised Statutes 695C.030
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Evidence of coverage: means any certificate, agreement or contract issued to an enrollee setting forth the coverage to which the enrollee is entitled. See Nevada Revised Statutes 695C.030
- Health maintenance organization: means any person which provides or arranges for provision of a health care service or services and is responsible for the availability and accessibility of such service or services to its enrollees, which services are paid for or on behalf of the enrollees on a periodic prepaid basis without regard to the dates health services are rendered and without regard to the extent of services actually furnished to the enrollees, except that supplementing the fixed prepayments by nominal additional payments for services in accordance with regulations adopted by the Commissioner shall not be deemed to render the arrangement not to be on a prepaid basis. See Nevada Revised Statutes 695C.030
- Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
2. The health maintenance organization may limit its liability on the treatment of the temporomandibular joint to:
(a) No more than 50 percent of the usual and customary charges for such treatment actually received by an enrollee, but in no case more than 50 percent of the maximum benefits provided by the evidence of coverage for such treatment; and
(b) Treatment which is medically necessary.
3. Any provision of an evidence of coverage subject to the provisions of this chapter and issued or delivered on or after January 1, 1990, which is in conflict with this section is void.