State Law

New Mexico Statutes Ann-Chapter 59A-Article 22B. Prior Authorization

07/20/2020 New Mexico Section 59A-22B-2


Medical Necessity-Definition

See bold text below:

As used in the Prior Authorization Act:

A. “adjudicate” means to approve or deny a request for prior authorization;

B. “auto-adjudicate” means to use technology and automation to make a near-real-time determination to approve, deny or pend a request for prior authorization;

C. “covered person” means an individual who is insured under a health benefits plan;

D. “emergency care” means medical care, pharmaceutical benefits or related benefits to a covered person after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could be reasonably expected by a reasonable layperson to result in jeopardy to a person’s health, serious impairment of bodily functions, serious dysfunction of a bodily organ or part or disfigurement to a person;

E. “health benefits plan” means a policy, contract, certificate or agreement, entered into, offered or issued by a health insurer to provide, deliver, arrange for, pay for or reimburse any of the costs of medical care, pharmaceutical benefits or related benefits;

F. “health care professional” means an individual who is licensed or otherwise authorized by the state to provide health care services;

G. “health care provider” means a health care professional, corporation, organization, facility or institution licensed or otherwise authorized by the state to provide health care services;

H. “health insurer” means a health maintenance organization, nonprofit health care plan, provider service network, medicaid managed care organization or third-party payer or its agent;

I. “medical care, pharmaceutical benefits or related benefits” means medical, behavioral, hospital, surgical, physical rehabilitation and home health services, and includes pharmaceuticals, durable medical equipment, prosthetics, orthotics and supplies;

J. “medical necessity” means health care services determined by a health care provider, in consultation with the health insurer, to be appropriate or necessary according to:

(1) applicable, generally accepted principles and practices of good medical care;

(2) practice guidelines developed by the federal government or national or professional medical societies, boards or associations; or

(3) applicable clinical protocols or practice guidelines developed by the health insurer consistent with federal, national and professional practice guidelines, which shall apply to the diagnosis, direct care and treatment of a physical or behavioral health condition, illness, injury or disease;

K. “medical peer review” means review by a health care professional from the same or similar practice specialty that typically manages the medical condition, procedure or treatment under review for prior authorization;

L. “office” means the office of superintendent of insurance;

M. “pend” means to hold a prior authorization request for further clinical review;

N. “pharmacy benefits manager” means an agent responsible for handling prescription drug benefits for a health insurer; and

O. “prior authorization” means a pre-service determination that a health insurer makes regarding a covered person’s eligibility for health care services, based on medical necessity, the appropriateness of the site of services and the terms of the covered person’s health benefits plan.

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