If your workers' comp claim has been denied, or you have a dispute with the insurance company about your benefits, you can file an appeal with the Nevada Department of Administrations (DOA). The DOA has two tiers of administrative review which give you the opportunity to challenge your employer and its insurer. (For an overview of eligibility and benefits, see our article on filing a Nevada workers' comp claim).
In most cases, the first step is to request a hearing before a Hearing Officer at the DOA. The DOA has a Request for Hearing form available on its website. You must complete the form, attach a copy of the denial letter from the insurance company, and send both to one of the addresses listed below. The form must be filed within 70 days from the date of the insurer's denial letter.
Nevada Department of Administration
2200 S. Rancho Drive, Ste 210
Las Vegas, NV 89102
Nevada Department of Administration
1050 E. Williams Street, Ste 400
Carson City, NV 89701
The DOA will typically schedule a short, informal hearing before a Hearing Officer within 30 days of your request. The hearing is usually held in person at the Las Vegas or Carson City offices. During the hearing, the Hearing Officer will hear from both sides, review evidence submitted by the parties, and make a decision. If you disagree with the Hearing Officer's decision, you may move on to the next step and request review by an Appeals Officer.
To appeal the Hearing Officer's decision, you must file a Request for Hearing Before Appeals Officer form with the DOA within 30 days of the Hearing Officer's decision. You must complete the form, attach a copy of the Hearing Officer's decision, and mail both to the same address to which you sent your initial appeal request.
The Appeals Officer hearing is more formal than the review by the Hearing Officer. Everything that takes place at the hearing will be recorded and put into a written transcript. The Appeals Officer will conduct a completely new and separate hearing, so you can't simply rely on the evidence you submitted to the Hearing Officer. You will have to resubmit any evidence that you want the Appeals Officer to consider. If you are unhappy with the Appeals Officer's decision, you may appeal through the Nevada court system (see below).
The appeals process is slightly different if your employer has contracted with a managed care organization (MCO) to provide a network of authorized health care providers. Nevada law requires injured workers and MCOs to try to resolve disputes informally before going through the DOA's appeal process.
If you disagree with any decision by the MCO, you must give the MCO written notice within 14 days of the disputed decision. The MCO then has 14 days to respond to your letter. If you're unhappy with the MCO's response, or the MCO fails to respond at all, you may then request a hearing before the Appeals Officer within 30 days. In other words, you can skip the step of requesting review by the Hearing Officer.
If you are not satisfied with the Appeals Officer's decision, you may file a petition with a Nevada district court. You must file a Petition for Judicial Review with the District Court within 30 days of the Appeals Officer's decision. Complicated procedural rules apply to any case brought in civil court, including appeals of workers' compensation denials. If you haven't already, you should consult with a workers' comp attorney before filing an appeal in court.
Nevada offers free legal representation to injured workers through the Nevada Attorney for Injured Workers (NAIW), a state agency designed to help workers through the appeals process. The NAIW will appoint a lawyer to represent you in your Appeals Officer hearing. Your NAIW lawyer may also continue to represent you for free in your state court appeal. However, you will typically not receive representation for the more informal Hearing Officer review.