PRIOR AUTHORIZATION DATA CALL

ST ATE OF NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE -r- ILl a"a 'a' - Q L) z 7Q Cl DEPUTY SUPERINTENDENT Robert E. Doucette, Jr. 4&1 DEPUTY SUPERINTENDENT OIRCE OF NEW MEXICO iuvibixixotht SUPERINTENDENT OF INSURANCE John G. Franci BULLETIN 2019-011 July 19, 2019 Andy Romero TO: ALL INSURANCE CARRIERS THAT OFFER HEALTH BENEFITS PLANS SUBJECT TO THE HEALTH INSURANCE PRIORAUTHORIZATIONACT. RE: PRIORAUTHORIZATIONDATACALL THE FOLLOWING BULLETIN is issued pursuant to Sections 59A-2-8 and 59A-2-10, NMSA 1978, and 13.1.2.1 to 13.1.2.10 NMAC. OnApril 4, 2019, Governor Michelle Lujan Grisham signed Senate Bill 188, the Health InsurancePriorAuthorizationAct("theAct"). TheActrequirestheOfficeofSuperintendentof Insurance ("OSI") to collect and issue a report on each health insurer's use of prior authorization protocols by September 1, 2019, and each September 1 therea'fter. Accordingly, all health insurers subject to the Health Insurance Prior Authorization Act shall submit the required data to OSI using the attached reporting form by 12:00 p.m. MST on August 15, 2019, to Rolanda Paria at rolanda.pana@state.ntn.us. The form is also available in an editable format on OSI's website or upon request. Insurers shall report data separately for fully-insured lines of business, Medicaid coverage, and coverage provided under the Health Care Purchasing Act. Reporting for fully- insured lines of business shall be aggregated for all markets. Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 100, Albuquerque, NM 87110 Main Phone: (505) 827-4601 i Satellite Phone: (505) 322-2186i Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us nd coverage provided under the Health Care Purchasing Act. Reporting for fully- insured lines of business shall be aggregated for all markets. Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 100, Albuquerque, NM 87110 Main Phone: (505) 827-4601 i Satellite Phone: (505) 322-2186i Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us l) U 1 I. l: l l N 2 D I 0-O l l I) a g c 2 Any person aggrieved by a bulletin may request a hearing before the Superintendent in accordance with Section 59A-4-15, NMSA 1978. If you have questions regarding this bulletin, please contact Rolanda Pafia at (505) 322- 2186 or rolanda.pana@state.nm.us. DONEANDORDEREDthis 44thdayofJuly20l9. G. FRANCHINI Superintendent of Insurance Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 100, Albuquerque, NA4 87110 Main Phone: (505) 827-4601 Satellite Phone: (505) 322-2186 Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us Company name: Line of business: Contact name: Contact phone number: Contact email address: Prior Authorization Report, 2018 Plan Year Prior authorization (PA) requests generally: Number Total number of PAs requested Total number of PAs denied Total number of PAs approved Total number of PAs unresolved orindefinitely pended PA requests for specified benefits: Prescription drug requests: Inpatient Outpatient Total number of PA requests for prescription drugs Number of PA requests for prescription drugs denied Number of PA requests for prescription drugs unresolved or indefinitely pended Mental health (MH) andsubstance use disorder (SUD) treatment PA requests: Number Total number of PA requests for MH and/or SUD benefits Number of PA requests for MH and/or SUD benefits denied Number of PA requests for MH and/or SUD benefits unresolved or indefinitely pended Processing time: 5 days 6-15 days 15-30 days 30 days + Number of de nresolved or indefinitely pended Mental health (MH) andsubstance use disorder (SUD) treatment PA requests: Number Total number of PA requests for MH and/or SUD benefits Number of PA requests for MH and/or SUD benefits denied Number of PA requests for MH and/or SUD benefits unresolved or indefinitely pended Processing time: 5 days 6-15 days 15-30 days 30 days + Number of decisions on nonurgent/nonemergent PA requests completed within.... 24 hours 25-48 hours 49-72 hours 72 hours + Number of decisions on urgent/emergent PA requests completed within.... PA approval/denial frequency: CPTcodes (induding modifiers, if applicable) and descriptors of the ten covered services for which PA is most frequently DENIED CPT Code Descriptor CPTcodes (including modifiers, if applicable) and descriptors of the ten covered services for which PA /s most frequentlyAPPROVED CPT Code Descriptor