New Mexico Administrative Code
Title 13 - INSURANCE
Chapter 10 - HEALTH INSURANCE
Part 31 - PRIOR AUTHORIZATION
Section 13.10.31.10 - DOCUMENTATION AND TRANSPARENCY
Universal Citation: 13 NM Admin Code 13.10.31.10
Current through Register Vol. 35, No. 18, September 24, 2024
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.
Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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