Definitions

Terms used in these rules are as defined in Section 59A-22B-2 NMSA 1978, and in 13.10.29 NMAC, except as supplemented and superseded below. A. “Benefit” means any medical service, medical service location, medical provider selection, pharmaceutical, or medical supply that is the subject of a prior authorization request. B. “Utilization review organization” or “URO” means an entity engaged by a carrier to determine medical necessity for covered services. A URO includes a pharmacy benefits manager (“PBM”) who determines medical necessity for a carrier’s prescription drug coverage.