PRIOR AUTHORIZATION FORM AND PROCESS FOR OBTAINING APPROVAL OF ALTERNATIVE PRIOR AUTHORIZATION REQUEST FORM

STATE OF NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE SUPERINTENDENT OF INSURANCE Alice T. Kane SANTA FE LOCATION (MAIN OFFICE) (OVERNIGHT/SECOND DAY MAIL ONLY) 1120 Paseo De Peralta, 4th Floor Santa Fe, New Mexico 87501 (USPS MAIL ONLY) P O Box 1689 Santa Fe, New Mexico 87504 Main Phone: (505) 827-4601 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us BULLETIN 2025-001 January 9, 2025 TO: HEALTH INSURERS THAT OFFER OR ADMINISTER HEALTH BENEFIT PLANS SUBJECT TO THE PRIOR AUTHORIZATION ACT AND EVERY PERSON SUBJECT TO THE REQUIREMENTS OF RULE 13.10.31 NMAC, PRIOR AUTHORIZATION RE: PRIOR AUTHORIZATION FORM AND PROCESS FOR OBTAINING APPROVAL OF ALTERNATIVE PRIOR AUTHORIZATION REQUEST FORM FROM THE OFFICE OF SUPERINTENDENT OF INSURANCE (OSI) REPEAL NOTE: This bulletin repeals Bulletin No. 2019-014 dated September 3, 2019, and Bulletin No. 2021-027, dated December 15, 2021. EXPIRATION: This bulletin shall automatically expire on January 9, 2026, unless extended by the OSI. This bulletin is issued pursuant to NMSA 1978, Sections 59A-2-8, 59A-2-10, 59A-22B-1 through 59A-22B-8, the Prior Authorization Act, 13.12.2.1 to 13.1.2.10 NMAC, and 13.10.31.10 NMAC. The Prior Authorization Act required the Office of Superintendent of Insurance (OSI or Superintendent) 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 in NMSA 1978, Section 59A-22B-4(B): 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 B U L L E T I N 2 0 2 5 - 0 0 1 P a g e | 2 SANTA FE LOCATION (MAIN OFFICE) (OVERNIGHT/SECOND DAY MAIL ONLY) 1120 Paseo De Peralta, 4th Floor Santa Fe, New Mexico 87501 (USPS MAIL ONLY) P O Box 1689 Santa Fe, New Mexico 87504 Main Phone: (505) 827-4601 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us uniform prior authorization form shall conform to the requirements established for Medicare and Medicaid medical and pharmacy prior authorization requests. Beginning January 1, 2020, the OSI began requiring all health insurers subject to the Act to accept only the attached New Mexico Uniform Prior Authorization Form from health care providers. Also, the OSI required that by January 1, 2021, all health insurers had to allow for the electronic submission of this form via an easily accessible, secure electronic portal. Process for Requesting Use of a Non-uniform Prior Authorization Request Form 13.10.31.10(A)(2) NMAC provides that a “carrier may ask the Superintendent to approve a non-uniform prior authorization request form.” This bulletin explains how a carrier shall make such a request, and when such a request is required. The instructions in this bulletin also apply to a Utilization Review Organization (URO) contracted by a carrier to conduct prior authorization reviews. All carriers and their contractors must be in compliance with the requirements in this bulletin. The New Mexico Uniform Prior Authorization Form is available upon request from OSI or on OSI’s website at the following Internet link: Office of Superintendent of Insurance A carrier that wishes to use a non-standard prior authorization request form that was not proposed and stipulated to by a provider or a provider group must ask the Superintendent to approve the non-standard prior authorization form. The declaratory request by a carrier or its URO shall ask the Superintendent to determine and declare whether the requestor has the right to use a proposed non-uniform prior authorization request form. A request by a URO shall identify the carrier who the URO represents, and the URO shall certify that it is authorized to make the request on behalf of that carrier with its informed consent. All requests shall be sent to the following email address: OSI.PAform@osi.nm.gov Upon receiving the request, the Superintendent will appoint an Office of Superintendent of Insurance (OSI) staff person to evaluate the request and recommend to the Superintendent whether the proposed form should be approved. OSI staff shall be empowered to solicit any evidence, justification or comment important to that determination. OSI has 30 days to recommend changes and/or accept the form as submitted. If there are recommended changes the carrier shall accept those changes before posting the form on their website. B U L L E T I N 2 0 2 5 - 0 0 1 P a g e | 3 SANTA FE LOCATION (MAIN OFFICE) (OVERNIGHT/SECOND DAY MAIL ONLY) 1120 Paseo De Peralta, 4th Floor Santa Fe, New Mexico 87501 (USPS MAIL ONLY) P O Box 1689 Santa Fe, New Mexico 87504 Main Phone: (505) 827-4601 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us Request Necessity A non-uniform prior authorization request form on the OSI website is any standalone alternative to the New Mexico Uniform Prior Authorization Request Form, or any combination of forms that a carrier or its URO would accept as an alternative to the uniform request. Even if the OSI approves a non-uniform prior authorization request form, a carrier or its URO shall accept a New Mexico Uniform Prior Authorization Request Form. A carrier or its URO shall evaluate a prior authorization request using an approved, non-uniform form using the same processes and timelines that pertain to the uniform form. A carrier or its URO shall not require the submission of any form in addition to the uniform request as a condition to prior authorization. Mandating that a supplemental form be used in conjunction with the uniform request form constitutes a non-uniform prior authorization request process that must be approved by the Superintendent. A carrier may publish prior authorization request submission guides and forms that will assist a provider in identifying, organizing, and presenting the information that will facilitate review of a prior authorization request. Superintendent approval of such materials is not required unless a provider is required to submit a related form to obtain a prior authorization. A carrier shall clearly identify in the provider manual or provider portal all approved prior authorization request forms, and any optional guides and support forms. Approval of a non-standard form does not excuse a carrier, or its URO, from mandated prior authorization review timelines. Any person aggrieved by a bulletin may request a hearing before the Superintendent in accordance with Section 59A-4-15, NMSA 1978. Please direct any questions concerning this guidance to brenda.newell@osi.nm.gov ISSUED this 9th day of January 2025. __________________________________ ALICE T. KANE Superintendent of Insurance