State Mandated Provisions
Administrator Requirements under
Nevada Revised Statutes, Chapter 683A
This Exhibit B shall apply only if, to the extent, and for so long as, Administrator or its successor is subject to Nevada state insurance laws applicable to Third Party Administrators (“Applicable TPA Laws”) and to the extent that any of the administrative services provided by Administrator to Customer are subject to Applicable TPA Laws.
In addition to those terms defined in the Agreement of which this Exhibit B is a part, as used in this Exhibit B:
“Administrator” refers to Progyny, Inc. as defined in the Agreement.
“Third Party Administrators” includes those persons defined by law as third party administrators, third party health administrators, life and health administrators, insurance administrators, claims administrators, employee benefit plan administrators, or service companies.
“Covered Person” means an individual who is covered under the Customer’s insurance program.
“Customer” refers to the Insurer for whom Administrator will perform administrative services.
“Insurer,” as defined by NRS 683A.083, refers to an employer for whom a program of self-insurance is administered by an administrator.
MANDATORY PROVISIONS FOR ADMINISTRATOR AGREEMENTS BASED UPON STATE STATUTES
- State-Specific Rules for Nevada.
- Administrator shall maintain at its principal office adequate books and records of all transactions between itself, Insurer and the insureds. The books and records must be maintained in accordance with prudent standards of recordkeeping for insurance and with regulations of the Commissioner of the Nevada Division of Insurance (“Commissioner”) for a period of 5 years after the transaction to which they respectively relate. After the 5-year period, Administrator may remove the books and records from Nevada, store their contents on microfilm or return them to Insurer.
- The Commissioner may examine, audit and inspect books and records maintained by Administrator under the provisions of this section to carry out the provisions of NRS 679B.230 to 679B.300, inclusive.
- The names and addresses of insured persons or any other material which is in the books and records of Administrator are confidential except when used in proceedings against Administrator.
- Insurer may inspect and examine all books and records to the extent necessary to fulfill all contractual obligations to insured persons, subject to restrictions in the written agreement between Insurer and Administrator.
Administrator will not collect insurance charges and premiums on behalf of Insurer.
- Administrator shall approve or deny a claim relating to health insurance coverage within thirty (30) days after Administrator receives the claim. If the claim is approved, Administrator shall pay the claim within thirty (30) days after it is approved. Except as otherwise provided in NRS 683A.0879, if the approved claim is not paid within that period, Administrator shall pay interest on the claim at a rate of interest equal to the prime rate at the largest bank in Nevada, as ascertained by the Nevada Commissioner of Financial Institutions, on January 1 or July 1, as the case may be, immediately preceding the date on which the payment was due, plus 6 percent. The interest must be calculated from thirty (30) days after the date on which the claim is approved until the date on which the claim is paid.
- If Administrator requires additional information to determine whether to approve or deny the claim, Administrator shall notify the claimant of his request for the additional information within twenty (20) days after Administrator receives the claim. Administrator shall notify the provider of health care of all the specific reasons for the delay in approving or denying the claim. Administrator shall approve or deny the claim within thirty (30) days after receiving the additional information. If the claim is approved, Administrator shall pay the claim within thirty (30) days after he receives the additional information. If the approved claim is not paid within that period, Administrator shall pay interest on the claim in the manner prescribed in NRS 683A.0879(1).
- Administrator shall not request a claimant to resubmit information that the claimant has already provided to Administrator, unless Administrator provides a legitimate reason for the request and the purpose of the request is not to delay the payment of the claim, harass the claimant or discourage the filing of claims.
- Administrator shall not pay only part of a claim that has been approved and is fully payable.
- A court shall award costs and reasonable attorney’s fees to the prevailing party in an action brought pursuant to NRS 683A.0879.
- The payment of interest provided for in NRS 683A.0879(1) for the late payment of an approved claim may be waived only if the payment was delayed because of an act of God or another cause beyond the control of Administrator.
- The Nevada Division of Insurance may require Administrator to provide evidence which demonstrates that Administrator has substantially complied with the requirements set forth in NRS 683A.0879, including, without limitation, payment within thirty (30) days of at least 95 percent of approved claims or at least 90 percent of the total dollar amount for approved claims.
- If the Nevada Division of Insurance determines that Administrator is not in substantial compliance with the requirements set forth in NRS 683A.0879, the Nevada Division of Insurance may require Administrator to pay an administrative fine in an amount to be determined by the Nevada Division of Insurance. Upon a second or subsequent determination that Administrator is not in substantial compliance with the requirements set forth in NRS 683A.0879, the Nevada Division of Insurance may suspend or revoke the certificate of registration of Administrator.
- If Administrator establishes a panel of providers of health care or contracts with an organization that establishes a panel of providers of health care, Administrator shall not charge a provider of health care or such an organization: (a) any fee to include the name of the provider of health care on the panel; or (b) any other fee related to establishing the provider of health care as a provider on the panel.
- If Administrator violates the provisions of NRS 683A.0868(1), Administrator shall pay to the provider of health care or organization, as appropriate, an amount that is equal to twice the fee charged to the provider of health care or the organization.
- A court shall award costs and reasonable attorney’s fees to the prevailing party in any action brought to enforce the provisions of NRS 683A.0868.
- In addition to any relief granted pursuant to NRS 683A.0868, if Administrator violates the provisions of NRS 683A.0868(1), the Nevada Division of Insurance shall require Administrator to suspend the prohibited activities until Administrator, as determined by the Nevada Division of Insurance: (a) complies with the provisions of NRS 683A.0868(1); and (b) refunds to all providers of health care or organizations, as appropriate, all fees obtained by Administrator in violation of NRS 683A.0868(1).
Each claim paid by Administrator from money collected for or on behalf of Insurer must be paid by a check or draft upon and as authorized by Insurer.
- The compensation paid to Administrator for its services may be based upon premiums or charges collected, on number of claims paid or processed or on another basis agreed upon by Administrator and Insurer, except as provided in subsection (2) below.
- Compensation paid to Administrator may not be based upon or contingent upon: (a) The claim experience of the policies which it handled. (b) The savings realized by Administrator by adjusting, settling or paying the losses covered by Insurer.
Schedule of Payments
If Administrator contracts with a provider of health care to provide health care to an insured, Administrator shall: (1) if requested by the provider of health care at the time the contract is made, submit to the provider of health care a copy of the schedule of payments applicable to the provider of health care; or (2) if requested by the provider of health care at any other time, submit to the provider of health care the schedule of payments specified in (1) within seven (7) days after receiving the request.