Nevada Revised Statutes Title 57. Insurance § 683A.376. Definitions

1. “Agent who performs utilization review” includes any person who performs such review except a person acting on behalf of the Federal Government, but only to the extent that the person provides the service for the Federal Government or an agency thereof.

2. “Insured” means a natural person who has contracted for or participates in coverage under a policy of insurance, a contract with a health maintenance organization, a plan for hospital, medical or dental services or any other program providing payment, reimbursement or indemnification for the costs of health care for the natural person, his or her dependents, or both.

3. “Utilization review” means a system that provides, at a minimum, for review of the necessity and appropriateness of the allocation of health care resources and services provided or proposed to be provided to an insured or to any person claiming benefits against a policy of the insured.  The term does not include responding to requests made by an insured for clarification of his or her coverage.