Scope; Definitions; General Requirements; Prior Authorization Submission; Documentation and Transparency; Auto-Adjudication; Reserved; Penalties; Severability
See bold text below:
Section 126.96.36.199. Scope
These rules apply to every:
1. health insurer as defined in Subsection H of Section 59A-22B-2 NMSA 1978;
2. multiple employer welfare arrangement; and
3. 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of these rules supersede any conflicting provision of any rule previously adopted by the superintendent, and are superseded by any conflicting provision of federal or state law applicable to a Medicaid managed care organization.
Section 188.8.131.52. 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used in these rules are as defined in Section 59A-22B-2 NMSA 1978, and in 13.10.29 NMAC, except as supplemented and superseded below.
1. “Benefit” means any medical service, medical service location, medical provider selection, pharmaceutical, or medical supply that is the subject of a prior authorization request.
2. “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.
Section 184.108.40.206. 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.
1. 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.
2. 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.
3. 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.
4. 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.
Section 220.127.116.11. 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.
Section 18.104.22.168. 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.
Section 22.214.171.124. 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 alive 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 4hours for expedited requests and two calendar days for standard requests, to provide the specified information.
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.
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.
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.
Section 126.96.36.199. [RESERVED]
Section 188.8.131.52. 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 Sections59A-1-18 and 59A-46-25 NMSA 1978.
Section 184.108.40.206. 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.