Questions may come up about the member’s health benefit plan. Most questions can be answered by contacting Nevada Health Solutions at 702-216-1653 or call the toll free number at 855-392-0778.
Information about the Appeal process may be obtained by contacting Nevada Health Solutions or your Health Plan’s Customer Service Department.
If a Nevada Health Solutions physician reviewer determines that the services requested does not meet medical necessity clinical criteria and sends an adverse determination letter, there are steps the member/ member’s representative, provider or facility may take to have a different physician reviewer consider the request for services. This is called an Appeal.
FIRST LEVEL APPEAL
A member/member’s representative, provider or facility may appeal any adverse determination either orally, electronically or in writing within one hundred eight (180) days of receipt of the adverse determination. Written First Level Appeal review requests should be mailed to:
Nevada Health Solutions
P.O. Box 61440
Las Vegas, Nevada 89160
When you file an appeal, be sure to let us know any new information you have that will help us make our decision. While your appeal is being reviewed, you can still send or deliver any additional information that you think will help us make the decision.
When reviewing your appeal, we will:
An expedited appeal is a request for review of emergency care, care for life-threatening conditions, or continued stays for hospitalized patients. An expedited appeal decision is made within seventy two (72) hours of the request for appeal.
If the member’s health benefit plan is subject to the Employee Retirement Income Security Act of 1974 (ERISA, and all internal levels of appeals have been exhausted, the member has a right to bring a civil action under 502 (a) of ERISA.
If the member’s health benefit plan is not subject to ERISA and the member has a life expectancy of less than two years and the proposed services were considered experimental/investigational, the member may seek information regarding an external appeal process administered by the Insurance Department.
OTHER MEMBER RIGHTS