REPEALED PRIOR AUTHORIZATION FORM- SEE BULLETIN 2025-001

# STATE OF NEW MEXICO ## OFFICE OF SUPERINTENDENT OF INSURANCE DEPUTY SUPERINTENDENT Robert E. Doucette, Jr.  DEPUTY SUPERINTENDENT Andy Romero SUPERINTENDENT OF INSURANCE John G. Franchini BULLETIN 2019-014 SEPTEMBER 3, 2019 SEP 3 2019 2019 SEP - 3 PM 4:43 OFFICE OF SUPERINTENDENT OF INSURANCE TO: HEALTH INSURERS THAT OFFER OR ADMINISTER HEALTH BENEFITS PLANS SUBJECT TO THE HEALTH INSURANCE PRIOR AUTHORIZATION ACT RE: PRIOR AUTHORIZATION FORM 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. On April 4, 2019, Governor Michelle Lujan Grisham signed Senate Bill 188, the Health Insurance Prior Authorization Act (“the Act”). The Act requires the Office of Superintendent of Insurance (“OSI”) to issue a standardized prior authorization form by September 1, 2019, which shall be used by all health insurers and health care providers in the state for prior authorization requests beginning on January 1, 2020. Specifically, the Act states: On or before September 1, 2019, the office shall, in collaboration with health insurers and health care providers, promulgate a uniform prior authorization form for medical care, pharmaceutical benefits or related benefits to be used by every health insurer and health care provider after January 1, 2020; provided that the uniform prior authorization form shall conform to the requirements established for Medicare and Medicaid medical and pharmacy prior authorization requests. Accordingly, all health insurers subject to the Act shall begin accepting only the attached prior authorization form from health care providers on January 1, 2020. By January 1, 2021, all health insurers shall allow for the electronic submission of this form via an easily accessible, secure electronic portal. The form is also available on OSI’s website or upon request. ior authorization requests. Accordingly, all health insurers subject to the Act shall begin accepting only the attached prior authorization form from health care providers on January 1, 2020. By January 1, 2021, all health insurers shall allow for the electronic submission of this form via an easily accessible, secure electronic portal. The form is also available on OSI’s website or upon request. 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 | Satellite Phone: (505) 322-2186 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us BULLETIN 2019-014 Page | 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 Paige Duhamel by phone at (505) 660-7108 or by email at paige.duhamel@state.nm.us. DONE AND ORDERED this 3rd day of September 2019. JOHN 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, NM 87110 Main Phone: (505) 827-4601 | Satellite Phone: (505) 322-2186 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us | **New Mexico Uniform Prior Authorization Form** | | | | | --- | --- | --- | --- | | To file electronically, send to: [INSERT WEB ADDRESS HERE] | | | To file via facsimile, send to: [INSERT FAX NUMBER HERE] | | To contact the coverage review team for [INSERT PLAN NAME], please call [INSERT PHONE NUMBER] between the hours of [INSERT HOURS]. For after-hours review, please contact [INSERT PHONE NUMBER]. | | | | | **[1] Priority and Frequency** | | | | | a. Standard [ ] Services scheduled for this date: | | b. Urgent/Expedited [ ] Provider certifies that applying the standard review timeline may seriously jeopardize the life or health of the enrollee. | | | c NSERT PHONE NUMBER] between the hours of [INSERT HOURS]. For after-hours review, please contact [INSERT PHONE NUMBER]. | | | | | **[1] Priority and Frequency** | | | | | a. Standard [ ] Services scheduled for this date: | | b. Urgent/Expedited [ ] Provider certifies that applying the standard review timeline may seriously jeopardize the life or health of the enrollee. | | | c. Frequency Initial [ ] Extension [ ] Previous Authorization #: | | | | | **[2] Enrollee Information** | | | | | a. Enrollee name: | b. Enrollee date of birth: | | c. Subscriber/Member ID #: | | d. Enrollee street address: | | | | | e. City: | f. State: | | g. Zip code: | | **[3] Provider Information:** Ordering Provider [ ] Rendering Provider [ ] Both [ ] *Please note:* processing delays may occur if rendering provider does not have appropriate documentation of medical necessity. Ordering provider may need to initiate prior authorization. | | | | | a. Provider name: | b. Provider type/specialty: | | c. Administrative contact: | | d. NPI #: | | | e. DEA # if applicable: | | f. Clinic/facility name: | | | g. Clinic/pharmacy/facility street address: | | h. City, State, Zip code | i. Phone number and ext.: | | j. Facsimile/Email: | | **[4] Requested medical or behavioral health course of treatment/procedure/device information (skip to Section 8 if drug requested)** | | | | | a. Service description: | | | | | b. Setting/CMS POS Code Outpatient [ ] Inpatient [ ] Home [ ] Office [ ] Other* [ ] | | | | | c. *Please specify if other: | | | | | **[5] HCPCS/CPT/CDT/ICD-10 CODES** | | | | | a. Latest ICD-10 Code | b. HCPCS/CPT/CDT Code | | c. Medical Reason | | | | | | | | | | | | | | | | | | | | | | | | | | | **[6] Frequency/Quantity/Repetition Request** | | | | | a. Does this service involve multiple treatments? Yes [ ] No [ ] If "No," skip to Section 7. | | | | | b | | | **[5] HCPCS/CPT/CDT/ICD-10 CODES** | | | | | a. Latest ICD-10 Code | b. HCPCS/CPT/CDT Code | | c. Medical Reason | | | | | | | | | | | | | | | | | | | | | | | | | | | **[6] Frequency/Quantity/Repetition Request** | | | | | a. Does this service involve multiple treatments? Yes [ ] No [ ] If "No," skip to Section 7. | | | | | b. Type of service: | | | c. Name of therapy/agency: | | d. Units/Volume/Visits requested: | | e. Frequency/length of time needed: | | | **[8] Prescription Drug** | | | --- | --- | | a. Diagnosis name and code: | | | b. Patient Height (if required): | c. Patient Weight (if required): | | d. Route of administration Oral/SL [ ] Topical [ ] Injection [ ] IV [ ] Other* [ ] | | | *Explain if "Other:" | | | e. Administered: Doctor's office [ ] Dialysis Center [ ] Home Health/Hospice [ ] By patient [ ] | | Page 1 of 2 | f. Medication Requested | g. Strength (include both loading and maintenance dosage) | h. Dosing Schedule (including length of therapy) | i. Quantity per month or Quantity Limits | | --- | --- | --- | --- | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | j. Is the patient currently treated with the requested medication[s]? Yes* [ ] No [ ] | | | | | *If "Yes," when was the treatment with the requested medication started? Date: | | | | | k. Anticipated medication start date (MM/DD/YY): | | | | | l. General prior authorization request. Explain the clinical reason(s) for the requested medications, including an explanation for selecting these medications over alternatives: | | | | | l [s]? Yes* [ ] No [ ] | | | | | *If "Yes," when was the treatment with the requested medication started? Date: | | | | | k. Anticipated medication start date (MM/DD/YY): | | | | | l. General prior authorization request. Explain the clinical reason(s) for the requested medications, including an explanation for selecting these medications over alternatives: | | | | | l. Rationale for drug formulary or step-therapy exception request: | | | | | ☐ Alternate drug(s) contraindicated or previously tried, but with adverse outcome, e.g., toxicity, allergy, or therapeutic failure, Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s). | | | | | ☐ Patient is stable on current drug(s), high risk of significant adverse clinical outcome with medication change. Specify anticipated significant adverse clinical outcome below. | | | | | ☐ Medical need for different dosage and/or higher dosage, Specify below: (1) Dosage(s) tried; (2) explain medical reason. | | | | | ☐ Request for formulary exception, Specify below: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective, length of therapy on each drug and outcome | | | | | ☐ Other (explain below) | | | | | Required explanation(s): | | | | | m. List any other medications patient will use in combination with requested medication: | | | | | n. List any known drug allergies: | | | | | [8] Previous services/therapy (including drug, dose, duration, and reason for discontinuing each previous service/therapy) | | | | | a. | | Date Discontinued: | | | b. | | Date Discontinued: | | | c. | | Date Discontinued: | | ### [9] Attestation atient will use in combination with requested medication: | | | | | n. List any known drug allergies: | | | | | [8] Previous services/therapy (including drug, dose, duration, and reason for discontinuing each previous service/therapy) | | | | | a. | | Date Discontinued: | | | b. | | Date Discontinued: | | | c. | | Date Discontinued: | | ### [9] Attestation I hereby certify and attest that all information provided as part of this prior authorization request is true and accurate. Requester Signature Date DO NOT WRITE BELOW THIS LINE. FIELDS TO BE COMPLETED BY PLAN. Authorization # Contact name Contact's credentials/designation Page 2 of 2