New Mexico Register / Volume XXXII,
Issue 11 /June 8, 2021
TITLE 13 INSURANCE
CHAPTER 10 HEALTH INSURANCE
PART 31 PRIOR AUTHORIZATION
13.10.31.1 ISSUING AGENCY: Office of
Superintendent of Insurance (“OSI”).
[13.10.31.1
NMAC - N, 01/01/2022]
13.10.31.2 SCOPE: These rules apply
to every:
A. health insurer
as defined in Subsection H of Section 59A-22B-2 NMSA 1978;
B. multiple employer
welfare arrangement; and
C. Medicaid managed
care organization, that requires prior authorization as a condition to payment
for a medical service, pharmaceutical, or medical supply benefit. The subject entities are referred to
collectively herein as “carriers” and individually as a “carrier.” The requirements of these rules
supersede any conflicting provision of any rule previously adopted by the
superintendent, and are superseded by any conflicting provision of federal or
state law applicable to a Medicaid managed care organization.
[13.10.31.2
NMAC - N, 01/01/2022]
13.10.31.3 STATUTORY AUTHORITY: Section 59A-2-9.8
NMSA 1978, Section 59A-15-20 NMSA 1978; Sections 59A-22B-1 through 59A-22B-5 NMSA
1978; and Sections 59A-57-1 through 59A-57-11 NMSA 1978.
[13.10.31.3
NMAC - N, 01/01/2022]
13.10.31.4 DURATION: Permanent.
[13.10.31.4
NMAC - N, 01/01/2022]
13.10.31.5 OBJECTIVE: To establish and
standardize oversight, reporting, transparency and confidentiality procedures
for prior authorization processes.
[13.10.31.5
NMAC - N, 01/01/2022]
13.10.31.6 EFFECTIVE DATE: January 1, 2022,
unless a later date is cited at the end of a section.
[13.10.31.6
NMAC - N, 01/01/2022]
13.10.31.7 DEFINITIONS: Terms used in
these rules are as defined in Section 59A-22B-2 NMSA 1978, and in 13.10.29 NMAC,
except as supplemented and superseded below.
A. “Benefit” means any medical service, medical
service location, medical provider selection, pharmaceutical, or medical supply
that is the subject of a prior authorization request.
B. “Utilization review organization” or “URO”
means an entity engaged by a carrier to determine medical necessity for covered
services. A URO includes a pharmacy benefits manager (“PBM”) who determines
medical necessity for a carrier’s prescription drug coverage.
[13.10.31.7
NMAC - N, 01/01/2022]
13.10.31.8 GENERAL REQUIREMENTS: A carrier shall
comply with the standard prior authorization processes specified in these
rules.
A. Responsibility for
requesting prior authorization.
(1) A
carrier shall accept a prior
authorization request submitted by a provider or by a covered person.
(2) If
a covered person directly submits, or attempts to submit, a prior authorization
request, the carrier shall provide the covered person all assistance required
to properly submit the request, including assistance with obtaining required
documentation and information to meet clinical guidelines.
(3) A
carrier shall prohibit its participating providers from billing a covered
person for a delivered benefit for which prior authorization was required if
the provider failed to obtain the required authorization without the covered
person’s informed and documented consent.
(4) A
carrier shall allow non-participating providers to:
(a) request prior authorizations
and submit supporting documentation by all submission methods authorized by
these rules; and
(b) receive
confirmations and tracking numbers as required by these rules.
B. Requests for multiple benefits.
(1) A
carrier shall allow a provider to submit a single request for multiple benefits
that will be delivered contemporaneously to the same covered person.
(2) If
a carrier does not grant prior authorization for all of the benefits in a
multiple benefit request, the carrier must clearly state which benefits are
approved and which are denied.
(3) A
carrier shall permit a provider or covered person to appeal the denial of any
benefits regardless of the number of benefits requested at one time.
C. Changes to prior authorization requirements.
(1) After
inception of coverage, a carrier shall not expand the list of benefits for
which prior authorization is required except when a new covered benefit is
added to the plan, when safety or other concerns have arisen with respect to
the benefit, when authorized by a state or federal regulatory agency, or as
indicated by changes in nationally recognized clinical guidance.
(2) After
inception of coverage, a carrier shall notify its network providers before
adding a prior authorization requirement.
(3) A
carrier may remove a prior authorization requirement at any time. A carrier who
removes a prior authorization requirement during a plan year shall notify its network
providers of the change as soon as practicable, and no more than 60 days after
the requirement is removed.
D. Retroactive denials. A carrier shall
not retroactively deny authorization if a provider relied upon a written prior
authorization from the carrier received prior to providing the benefit, except
in those cases where there was material misrepresentation or fraud by the
provider.
E. Retrospective Authorization Requests. A
carrier shall establish written policies and guidance for the process and
circumstances under which it will consider a retrospective authorization. A
carrier’s policies shall not unreasonably limit the ability of a provider to
request or obtain a retrospective authorization.
F. Mental health parity. A carrier shall
not apply more restrictive prior authorization requirements for covered
behavioral health services than for covered medical and surgical services.
G. Expiration of prior authorization. A
carrier’s prior authorization shall expire no sooner than 60 days from the date
of approval, unless an earlier expiration is warranted by the clinical
criteria. A carrier shall allow a request for the extension of an authorization
as supported by the clinical criteria.
H. Reasonable prior authorization requirements.
A carrier shall not impose a prior authorization requirement that deters or unreasonably
delays the delivery of medically necessary and covered benefits warranted by
prevailing standards of care. A carrier shall only require prior authorization
for a benefit to the extent reasonably necessary to contain inappropriate or
unnecessary costs or implement demonstrably effective medical management
services.
[13.10.31.8
NMAC - N, 01/01/2022]
13.10.31.9 PRIOR AUTHORIZATION SUBMISSION:
A. A carrier shall:
(1) accept
prior authorization requests submitted at any time prior to the delivery of
service;
(2) accept
prior authorization requests telephonically and by facsimile;
(3) offer
at least one bi-directional electronic prior authorization portal;
(4) allow
a provider to upload in a secure manner the supporting documentation associated
with an electronic prior authorization request, subject to reasonable limits on
file type and size;
(5) accept
and consider any information from a provider that will assist in the review;
(6) require
only the information necessary to evaluate the request;
(7) not
reject a request solely on the basis of documentation or submission errors that
do not prevent substantive review;
(8) ensure
that the system it operates for receiving electronic prior authorization
requests and supporting documentation satisfies all applicable Health Insurance
Portability and Accountability Act (“HIPAA”) transaction requirements and operating
rules no later than the effective date that such requirements and rules are
established;
(9) make
its system available for accepting electronic prior authorization requests and
supporting documentation 24-hours per day, seven-days per week. Planned
maintenance or down time of the system shall be performed during historically
low-utilization periods; and
(10) notify
providers of planned maintenance or downtime of the system at least 24-hours in
advance. A carrier shall notify providers of any unplanned system downtime as
soon as practicable.
B. Confirmation of receipt and tracking numbers.
(1) Within
one business day of receipt, a carrier shall confirm receipt of a prior
authorization request and any supporting documentation to the submitter. The
carrier also shall assign a unique tracking number to the request. The tracking
number shall identify the request throughout the processing cycle, including
after approval or denial.
(2) The
confirmation that includes the tracking number shall be communicated by
electronic portal, fax or email.
(3) A
carrier shall provide the tracking number of a prior authorization request to
the covered person upon request.
(4) A
carrier may assign other identifiers to a prior authorization request.
[13.10.31.9
NMAC - N, 01/01/2022]
13.10.31.10 DOCUMENTATION AND TRANSPARENCY:
A. Prior authorization forms.
(1) A
carrier shall accept the uniform prior authorization request form(s) developed
by the superintendent and found on the superintendent’s website at www.osi.state.nm.us.
(2) A
carrier may ask the superintendent to approve a non-uniform prior authorization
request form. If the superintendent approves the non-uniform request form, the
carrier shall prominently publish the form to providers on its website.
B. Document retention. A carrier shall
maintain a record of each prior authorization request and its associated
documentation. The carrier shall store the records in compliance with all
applicable state and federal privacy and security laws and regulations. The
record shall be retained for as long as required by federal and state document
retention guidelines, laws and regulations.
C. Access to information about services requiring
prior authorization.
(1) A
carrier shall make available on its member and provider websites a list of all benefits
for which a prior authorization is required. The list shall be presented
clearly and in readily understandable language appropriate for the intended
audience. The list shall be updated at least annually and upon notification to
providers of any change.
(2) Prior
authorization information presented on the provider website shall include general
clinical criteria requirements and shall list supporting documentation that is
expected to accompany the prior authorization request. If a prior authorization
is denied, the criteria used to deny the request shall be supplied to the
provider in full upon request.
(3) Information
on benefits requiring prior authorization, associated clinical criteria and
supporting documentation may be located in an area(s) of a website(s) that is
not accessible to a covered person, including the carrier’s prior authorization
portal.
(4) A
carrier shall provide an on-line search tool for any provider to use to search the
list of benefits that require prior authorization.
[13.10.31.10
NMAC - N, 01/01/2022]
13.10.31.11 AUTO-ADJUDICATION:
A. No later than January 1, 2022,
a carrier shall implement a process to auto-adjudicate electronically submitted
prior authorization requests.
(1) A
carrier shall comply with all statutory timelines applicable to prior
authorization review. A list of all statutory prior authorization review
timelines is posted on the OSI website.
(2) A
carrier may reject for correction an auto-adjudicated prior authorization
request for reasons other than medical necessity as long as the rejection is
completed within statutory timelines.
(3) A
carrier may pend an auto-adjudicated prior authorization request if it requires
manual review, as long as the review is completed within statutory timelines.
(4) A
carrier shall not automatically deny an auto-adjudicated prior authorization
request. A carrier shall only deny a prior authorization request based on a
live review.
B. Incomplete information. If a provider
fails to supply sufficient information to evaluate a prior authorization
request, the carrier shall allow the provider a reasonable amount of time,
taking into account the circumstances of the covered person, but not less than 4
hours for expedited requests and two calendar days for standard requests, to
provide the specified information.
C. Notice. A carrier shall provide written
notice to the provider and covered person of a determination to approve or deny
authorization. The Notice shall contain the reasons for a denial.
D. Delegation. A carrier may delegate one
or more of the obligations mandated by these rules to a qualified third party,
including a URO. A carrier who delegates any obligation mandated by these rules
remains responsible for compliance with the delegated obligation.
E. Reporting. At least annually, a carrier
shall report to the superintendent data and information about the
auto-adjudication process, when and as directed by the superintendent.
[13.10.31.11
NMAC - N, 01/01/2022]
13.10.31.12 [RESERVED]
[13.10.31.12
NMAC - N, 01/01/2022]
13.10.31.13 PENALTIES: In addition to
any applicable suspension, revocation or refusal to continue any certificate of
authority or license under the Insurance Code, a penalty for any violation of
this rule may be imposed against an insurer in accordance with Sections
59A-1-18 and 59A-46-25 NMSA 1978.
[13.10.31.13
NMAC - N, 01/01/2022]
13.10.31.14 SEVERABILITY: If any section of
this rule, or the applicability of any section to any person or circumstance,
is for any reason held invalid by a court of competent jurisdiction, the
remainder of the rule, or the applicability of such provisions to other persons
or circumstances, shall not be affected.
[13.10.31.14
NMAC - N, 01/01/2022]
History of 13.10.31
NMAC: [RESERVED]