provider information

You can download a copy of provider information by clicking here.On this page, you will find detailed information about the Nevada Health CO-OP’s (NHC) disease management and case management programs, as well as information regarding medical necessity criteria, accessing our Utilization Management staff and Utilization Management Decision-Making.

Disease Management and Case Management

The Nevada Health CO-OP has case management services available for all members. The CO-OP offers different levels of support from basic care coordination through complex case management for members who have experienced a catastrophic event or who have multiple illnesses. Our case management programs accept referrals from our members and their caregivers as well as from network practitioners and facility staff as well as discharge planners and Utilization Management (UM) staff.

To refer a member for case management, please call 702-823-2667 or toll-free at 855-606-2667. We also have specific disease management programs available for our members with diabetes and asthma. These programs focus on helping our members manage their chronic conditions. If you would like to refer a member to our disease management programs, please call 702-823-2667 or toll-free at 855-606-2667.

Medical Necessity Criteria

The Nevada Health CO-OP uses written criteria to assist in making Utilization Management (UM) decisions. If you would like to view our medical necessity criteria, please call the Health Advocacy Department at 702-823-2667 or toll-free at 855-606-2667.

Access to Utilization Management Staff

As a practitioner in our network, we understand that you may have questions about Utilization Management (UM). Our Utilization Management staff is available every work day during normal business hours, toll free at 855-606-2667. We also have TDD/TTY services available for our members. Just call Nevada Relay at 711 and then ask to be connected to 702-823-2667 or toll-free at 855-606-2667. For members whose preferred language is not English, we have language services available through our bilingual staff as well as three-way calling to an interpreter service.

Utilization Management Decision-Making

The Nevada Health CO-OP adheres to the following principles regarding Utilization Management (UM) decision-making:

  • UM decision-making is based only on appropriateness of care and service and existence of coverage.
  • The NHC does not reward practitioners or other individuals for issuing denials of coverage.
  • There are no financial incentives for UM decision makers that would encourage decisions that result in underutilization. NHC expressly ban such incentives.

Information about the Credentialing Process

The Nevada Health CO-OP and its delegates verify and assess the credentials you submit as part of its credentialing process when you join our Provider Network and every three years thereafter. During the credentialing verification process, discrepancies are sometimes identified between the information that you submit and that which we receive from your primary [as well as other outside] sources. When this happens you will be notified about any discrepancies. You may provide additional information as appropriate and desired. You may correct erroneous information submitted by another source. The correction must be written and sent to us within 30 calendar days from the date of the notification. All corrections and additional information will be included in the documents that is reviewed by the credentialing committee to render a decision about participation in our network. You may review information that we obtain to evaluate your application, CV, attestation or other documents.

If you would like to know the status of your application, please contact the Provider Advocacy Department. We can tell you when your application will be reviewed by the credentialing committee and the status of your application. If you have questions about credentialing issues or any of the above processes, please contact the Provider Advocacy Department.

Clinical Practice Guidelines

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