Nevada Surprise Billing Law (SBL) Overview
The Nevada Surprise Billing Law (SBL), effective January 1, 2020, is detailed in Nevada Revised Statutes (NRS) 439B.748, 439B.751, and 439B.754. The law governs reimbursement for out-of-network (OON) emergency services and includes specific provisions for arbitration and dispute resolution.
Key Provisions of the Nevada SBL
- Arbitration Process:
- Providers and payers have a 30-day window to object to payment and initiate arbitration.
- Reimbursement Standards:
- Recent Contractual Rates:
- Facilities: Reimbursement is based on contractual rates if the facility was in-network within the past 24 months.
- Practitioners: Reimbursement is based on contractual rates if the practitioner was in-network within the past 12 months.
- Fair and Reasonable Standard:
- When no recent contractual rates exist, reimbursement defaults to what is deemed fair and reasonable.
- Arbitration Thresholds:
- Claims below $5,000 are resolved through local arbitration.
- Claims above $5,000 are referred to the American Arbitration Association (AAA).
State and Federal Coordination
- Specified State Laws:
- The following statutes govern OON reimbursement for medically necessary emergency services in Nevada:
- NRS 439B.748: Applies predetermined payment amounts for OON emergency facilities if they had in-network contracts within the last 24 months.
- NRS 439B.751: Applies predetermined payment amounts for OON emergency providers if they had in-network contracts within the last 12 months.
- NRS 439B.754: Provides a method for determining reimbursement when:
- Facilities/providers lack recent in-network contracts (past 24 or 12 months).
- Contracts were terminated for cause by the third-party payer before expiration.
- Federal Independent Dispute Resolution (IDR):
- Federal IDR applies for:
- Cases not covered under NRS 439B.748, 751, and 754.
- OON services by nonparticipating air ambulance providers.
- The process is governed by Section 2799A-1(c) of the PHS Act and 45 CFR 149.510.
- CMS enforces the outcomes of federal IDR processes for cases in Nevada.
CMS Clarifications
In a letter from CMS to the Governor of Nevada (February 24, 2022), the following points were outlined:
- Nevada does not have an All-Payer Model Agreement to set OON rates.
- CMS recognizes NRS 439B.748, 751, and 754 as specified state laws for determining OON rates for emergency services.
- Federal IDR applies to services not covered by Nevada’s state laws, ensuring comprehensive dispute resolution for OON claims.
This framework aims to balance fair reimbursement while protecting patients from excessive billing disputes.
