Current through Register Vol. 35, No. 18, September 24, 2024
A.
Applicability. This section of the rule shall only apply to
fully-insured commercial coverages regulated by the superintendent.
B.
Review of covered benefits that
require prior authorizations. Annually, beginning in 2023, a carrier
shall review its prior authorization requirements for all covered benefits,
except for inpatient admissions to acute-care hospitals, including transfers,
in order to assess the continued utility of each requirement.
(1) At a minimum, a carrier's assessment
shall consider the following elements:
(a)
the approval rate for each covered benefit for which a prior authorization was
required;
(b) whether, based on
demonstrable evidence, including claims and clinical data, the prior
authorization requirement for each covered benefit protects patient safety or
generates better health outcomes, or both;
(c) whether, based on demonstrable evidence,
including claims and clinical data, the prior authorization requirement for
each covered benefit prevents the need for higher cost services;
(d) whether based on demonstrable evidence,
including claims and clinical data, the prior authorization requirement of each
covered benefit has deterred any reasonable suspicion of insurance fraud,
waste, or abuse;
(e) whether, based
on demonstrable evidence, including claims, clinical and operational data, and
considering both the providers' and the carrier's experience, the costs and
other administrative burdens associated with the prior authorization
requirement for a covered benefit outweigh the demonstrated benefits of the
requirement; and
(f) whether the
prior authorization requirement for a covered benefit, based on demonstrable
evidence including provider and member grievances, appeals and complaints, and
claims and clinical data, contributed to unreasonable or unnecessary delays in
treatment or adverse health outcomes for a covered person.
(2) A carrier shall conduct and complete the
review by the end of the second quarter of each calendar year, beginning in
2023, and shall evaluate the prior authorizations issued during the prior
calendar year.
(3) A carrier shall
identify those covered benefits, with the exception of inpatient admissions to
acute care hospitals, for which ninety percent of the prior authorization
requests for that benefit are approved.
(4) A carrier shall prepare a report of its
annual assessment that, at a minimum, contains its findings based on the
elements listed above, and identifies any change in prior authorization
requirements.
(a) The report shall be
submitted to the superintendent no later than October 31, 2023 and no later
than September 30th of every year thereafter,
beginning in 2024.
(b) The report
shall be submitted in the form and manner proscribed by annual guidance issued
pursuant to Subsection G of this Section.
(5) A carrier that enters the market in 2023
or later shall conduct its first prior authorization evaluation during its
second full calendar year in the market.
(6) If no protection of patient safety or no
better health outcomes related to prior authorization of a covered benefit can
be shown by the carrier, the prior authorization requirement must be eliminated
for 12 months or until the carrier is able to demonstrate additional evidence
to support its position.
C.
Assessment of prior authorization
request outcomes. Beginning in the first quarter of 2023, a carrier
shall annually evaluate its network providers' patterns of adherence to the
carrier's prior authorization criteria and policies in the preceding calendar
year. For the first year, prior authorization requests for admissions to
general acute care hospitals, psychiatric hospitals, and rehabilitation
hospitals, and durable medical equipment, including oxygen and disposable
medical supplies, shall be excluded from this evaluation. The superintendent
may include these services in subsequent years pursuant to the annual guidance
issued in accordance with Subsection G of this Section.
(1) A carrier shall identify providers who
are the most frequent submitters of prior authorizations, and who have a
consistent pattern of adherence to prior authorization requirements and
criteria as evidenced by prior authorization approval rates of ninety percent
or greater (a "high compliance provider").
(2) A carrier shall select no less than
thirty percent of its high compliance providers and shall:
(a) enter into an agreement with each
selected high-compliance provider on an alternative to the standard requirement
to submit a prior authorization request for a discreet service or set of
services that otherwise require one (an alternate arrangement); and
(b) the agreement with each provider shall
clearly describe the terms of the alternate arrangement, including under what
conditions the agreement can be terminated by a carrier or a provider. The
agreement shall include how the provider's ordering and prescribing performance
during the course of the alternative arrangement will be monitored and
evaluated, how results will be communicated, and how the agreement can be
extended beyond the base period of the agreement. At a minimum, the agreement
will be effective for 12 months.
(3) The high compliance providers selected
for alternate arrangements shall be representative of the various eligible
types of providers, including specialists, that participate in a carrier's
network, and the spectrum of covered benefits.
(4) The first year's alternative arrangements
shall go into effect on January 1, 2024, and all subsequent years' agreements
shall go into effect on the first day of the year.
(5) After the first year, a carrier shall
increase the number of high compliance providers with which it enters into
alternate arrangements by at least fifty percent of providers who had
alternative arrangements in the first year. If a carrier is not able to
increase the number of providers with alternate arrangements by at least fifty
percent compared to the prior year, the carrier shall request an exception
according to guidance issued by the superintendent. The exception request will
be subject to the approval of the superintendent.
(6) After the second year, a carrier shall
comply with specific performance requirements identified in guidance issued
pursuant to Subsection G of this Section.
(7) A carrier may elect to remove a prior
authorization requirement at any time, in accordance with Paragraph (3) of
Subsection C of Section
13.10.31.8 NMAC above.
D.
Annual Report. A
carrier shall, by September 30th of each year, submit a report to the
superintendent that:
(1) describes the
evaluation process and criteria used to identify high compliance
providers;
(2) lists the providers
identified, the providers with whom an alternate arrangement was made, and the
providers with whom negotiations are ongoing; and
(3) describes, in general, the terms of the
alternate arrangements entered into, including the effective dates of the
agreement, the services involved, performance evaluation, and communication
provisions; and
(4) describes
experiences making these alternate arrangements, the results of the alternate
arrangements when known, lessons learned, and recommendations to the
superintendent.
E.
New carriers. A carrier that enters the market in 2023 or later
shall conduct its first prior authorization evaluation in its second full
calendar year in the market unless the carrier has not met a threshold
enrollment of more than 500 members in which case the carrier shall file the
first year after it meets that enrollment threshold
F.
Data confidentiality and use.
Information reported to the superintendent concerning a specific, identifiable,
provider shall be deemed confidential pursuant to Subsection B of Section
59A-2-12 NMSA 1978. The
superintendent may publish and use any other reported information for any
regulatory purpose, including development and promulgation of rules to specify
minimum prior authorization incentive and corrective action programs.
G.
Guidance. The superintendent
shall annually publish guidance for carriers for the upcoming plan year. This
guidance shall include, at minimum, procedural reporting requirements, and any
specific performance requirements.
