The Office of Consumer Health Assistance assists consumers with researching and resolving concerns with their health plans to include appeals / grievances, external review requests, eligibility, billing, benefit and/or claim denial.

You should first contact your insurance company directly and ask to speak to “Member Services.” If they cannot or will not assist you, contact the Office of Consumer Health Assistance and they will review your claims and advocate on your behalf.

To begin a case, you will need to contact their office at 702-486-3587.

You can visit MyHPNStateofNevada.com for information about the services and programs available to you. The easy “I Need Help With” drop down menu includes topics most members have questions about.

You can sign in to the online member center to view your plan documents, request a new health plan ID card, see the status of a prior authorization and more.

If the information needed is not available online, you can call Member Services toll-free at 1-877-545-7378, TTY 711, Monday through Friday from 8 a.m. to 5 p.m. local time.

You can also visit in person at their Tenaya business office. Located in the northwest part of the Las Vegas Valley, Member Services is available to assist walk-in members with their questions. Their business office address is 2720 North Tenaya Way. Hours are Monday through Friday from 8 a.m. to 5 p.m. local time.

They have language services available for PEBP Participants, so they can communicate in the language they are most comfortable with. Member Services has Spanish-speaking staff members, as well as access to a language line.

You can call Member Services toll-free at 1-877-545-7378, TTY 711 with questions about your Health Plan of Nevada HMO plan. Business hours are Monday through Friday from 8 a.m. to 5 p.m. You can also access your plan information through the online member center. Create an account or sign in at MyHPNStateofNevada.com. Once you create an account, you can view your benefit information, claims history, pharmacy information, and more. This is a great way to manage your health care and get your plan information on the go.

You can call Member Services toll-free at 1-877-545-7378, TTY 711 with questions regarding your claims. Business hours are Monday through Friday from 8 a.m. to 5 p.m. Member Services can review your claims data, send it back for reprocessing, and request additional information from your provider, if needed. All correspondence is documented and every call to Member Services is recorded in order to track accuracy.

Members have 180 days from the date of the denial to file an appeal. You or your provider may submit a request or initiate an appeal for the informal review of a decision by calling Member Services or mailing a written request to:

Appeals and Grievances Department
Health Plan of Nevada
P.O. Box 15645 Las Vegas, NV 89114-5645

If your primary care provider is with Southwest Medical, you can see a Southwest Medical provider at any Southwest Medical location with available appointments. As a Health Plan of Nevada member, you can also visit a Southwest Medical Convenient Care or Urgent Care.

If you want to change your PCP, you can visit the online member center at MyHPNStateofNevada.com or call Member Services toll-free at 1-877-545-7378, TTY 711. If you only want to see your assigned PCP, you may have to contact them directly to see if you can get an expedited appointment.

Login to the E-PEBP Portal. Once you are logged in, select the link for HealthScope Benefits on the right side of the screen. Next, from the HealthScope Benefits home page, click on the Resource tab to the right labeled “Claims and Eligibility”. From there, you will be able to view current and past health claims for both medical and dental.

You have the right to ask the Plan Administrator or its designees to reconsider an Adverse Benefit Determination resulting in a denial, reduction, termination, failure to provide or make payments (in whole or in part) for a service or treatment, or rescission of coverage (retroactive cancellation).

If you receive an Explanation of Benefits (EOB) from Healthscope indicating the claim was denied, you will have 180 days to submit an appeal to the claims administrator. Failure to request a review in a timely manner will be deemed to be a waiver of any further right of review of appeal under the Plan unless the Plan Administrator determines that the failure was acceptable.

The written request for appeal must include:

• The name and social security number, or member identification number, of the Participant;
• A copy of the EOB and claim; and
• A detailed written explanation why the claim is being appealed.
• Information is mailed to the Claims Administrator

The decision on your appeal will be given to you in writing. Ordinarily, a decision on your appeal will be reached within 20 days after receipt of your request for appeal. If the appeal results in a denial of benefits in whole or in part, it will explain the reasons for the decision. It will also explain the steps necessary if you wish to proceed to a Level 2 appeal if you are not satisfied with the response at Level 1. NAC 287.670

To file a Level 2 appeal you would need to complete a Claim Appeal Request form. For questions on the Claim Appeal Request form, you will need to contact PEBP Customer Service at 1-800-326-5496. You would have to complete the request within 35 days after receiving the level 1 appeal decision and submitted to the Executive Officer of PEBP or his designee.

Your Level 2 appeal must include a copy of:

• The Level 1 review request;
• A copy of the decision made on review; and
• Any other documentation provided to the third party claims administrator by the Participant.
• Information mailed to the Executive Officer at PEBP or designee at 901 S. Stewart Street, Suite 1001, Carson City, Nevada 89701

A decision on a Level 2 appeal will be provided to you in writing within 30 days after the Level 2 appeal request is received by the Executive Officer or his designee, and will explain the reasons for the decision. If the appeal review results in a denial of Benefits in whole or in part, it will explain the reasons for the decision. NAC 287.680

An External Appeal may be requested by a you the Participant and/or your treating Physician after you have exhausted the internal claim appeal review process. You may have a right to have PEBP’s decision reviewed by independent health care professionals if PEBP’s decision involved making a judgment as to the Medical Necessity, appropriateness, health care setting, level of care or effectiveness of the health care setting or treatment you requested.

You must file a request for an External Review with the Office for Consumer Health Assistance if the request is filed within 4 months after the date of receipt of a notice of an Adverse Benefit Determination or final internal Adverse Benefit Determination. A standard External Review request form can be found on the PEBP website.

The request must be submitted to:

Office for Consumer Health Assistance
555 East Washington #4800
Las Vegas NV 89101
Phone: 702-486-3587, 888-333-1597
Fax 702-486-3586

For standard External Review, a decision will be made within 45 days of receiving the request.

Medical providers and members can contact Healthscope for questions about eligibility or benefits. Healthscope can be reached at 888-763-8232 or by e-mail at PEBP@healthscopebenefits.com.

For the Health Savings Account/Heath Reimbursement Account questions can be submitted to pebphsahra@healthscopebenefits.com.

If a Member would like to know if a procedure and/or service requires prior authorization or needs to notify of a hospital admission, contact, Hometown Health Case Management at 800-336-0123.