Nevada § 616D.440 - False claim for payment: Withholding by insurer of payment to provider of health care; procedure for withholding; appeal

§ 616D.440. False claim for payment: Withholding by insurer of payment to provider of health care; procedure for withholding; appeal

1. An insurer may withhold any payment due a provider of health care pursuant to the

provisions of chapters 616A to 616D, inclusive, or chapter 617 of NRS , in whole or in part, upon receipt of reliable evidence that the provider of health

care knowingly made a false statement or representation or knowingly concealed a material

fact to obtain the payment. The insurer may withhold such a payment without first notifying the provider of health

care of its intention to do so. 2. The insurer shall, within 5 days after withholding such a payment, send notice

of the withholding to the provider of health care by certified mail or electronic

transmission. The notice must: (a) Set forth the factual basis for the withholding, but need not disclose specific

information regarding the insurer's investigation; (b) Indicate that the payment is being withheld pursuant to the provisions of this

section; (c) Indicate that the payment is being withheld temporarily, as set forth in subsection

4, and describe the circumstances under which the withholding will be terminated; (d) Specify the charge submitted by the provider of health care for which the payment

is being withheld; and (e) Notify the provider of health care of the right of the provider of health care

to appeal the withholding. 3. A provider of health care may appeal the decision of the insurer to withhold payment

to an appeals officer pursuant to NRS 616C.360 . 4. Any payment withheld pursuant to the provisions of this section must be made to

the provider of health care if: (a) The insurer or the Attorney General determines that there is insufficient evidence

to prove that the provider of health care knowingly made a false statement or representation

or knowingly concealed a material fact to obtain the payment; or (b) A final judgment or decree was rendered in favor of the provider of health care

in a criminal proceeding arising out of the alleged misconduct.