SENATE BILL 263

57th legislature - STATE OF NEW MEXICO - first session, 2025

INTRODUCED BY

Martin Hickey

 

 

 

 

 

AN ACT

RELATING TO INSURANCE; ENACTING A NEW SECTION OF THE PRIOR AUTHORIZATION ACT TO REQUIRE HEALTH INSURERS TO ESTABLISH PROCEDURES TO GRANT EXEMPTIONS FROM THEIR PRIOR AUTHORIZATION PROCESS FOR HEALTH CARE PROVIDERS THAT MEET CERTAIN CRITERIA.

 

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

     SECTION 1. Section 59A-22B-1 NMSA 1978 (being Laws 2019, Chapter 187, Section 3) is amended to read:

     "59A-22B-1. SHORT TITLE.--[Sections 3 through 7 of this act] Chapter 59A, Article 22B NMSA 1978 may be cited as the "Prior Authorization Act"."

     SECTION 2. A new section of the Prior Authorization Act is enacted to read:

     "[NEW MATERIAL] PROCESS FOR GRANTING EXEMPTIONS FROM PRIOR AUTHORIZATION PROCESS CREATED--APPLICATIONS--ELIGIBILITY--RESCISSION--INDEPENDENT REVIEW.--

          A. For purposes of this section, "evaluation period" means a six-month period beginning each January and each June.

          B. A health care provider may apply to a health insurer for an exemption from its prior authorization process for a health care service. A health insurer shall grant the exemption request if, in the evaluation period prior to the exemption request, no less than ninety percent of the health care provider's prior authorization requests for that health care service have been approved upon initial submission or after appeal.

          C. A health insurer shall provide a written approval or denial of the prior authorization exemption request no later than ten business days after receipt of the request.

          D. When a health care provider's prior authorization exemption request is denied, a health insurer shall provide an explanation for the denial, including data, that sufficiently demonstrates how the request failed to meet the criteria established pursuant to Subsection A of this section.

          E. When a health care provider's prior authorization exemption request is approved, a health insurer shall provide the health care provider with information regarding the rights and obligations of the parties, including the effective date of the prior authorization exemption.

          F. Once, during each evaluation period, a health insurer may determine whether to continue or rescind a health care provider's prior authorization exemption.

          G. A health insurer shall not rescind a health care provider's prior authorization exemption unless the health insurer:

                (1) determines that less than ninety percent of the claims submitted by the health care provider during the previous evaluation period would have met the applicable medical necessity criteria, based on a retrospective review of a random sample of not fewer than five but no more than twenty claims; and

                (2) provides the health care provider with written notice not less than twenty-five days before the rescission is to take effect, including an explanation and the sample information used to make the determination.

          H. A health care provider has a right to a request an independent review of the determination to rescind a prior authorization exemption.

          I. A health insurer shall not require a health care provider to engage in an internal appeal process before requesting an independent review of the determination to rescind a prior authorization exemption.

          J. An independent review organization shall complete a review of an adverse determination no later than thirty days after the date a health care provider files a request for the review.

          K. A health care provider may request that the independent review organization conduct a review of another sample of claims using the process described in Subsection G of this section.

          L. The independent review shall be conducted by a person licensed to practice medicine in this state. If the rescission applies to a physician, the determination shall be made by a person licensed to practice medicine in this state who practices in the same or similar specialty as the physician requesting the review.

          M. The health insurer shall pay:

                (1) for an independent review of the adverse determination; and

                (2) a reasonable fee, determined by the New Mexico medical board, for any copies of medical records or other documents requested from the health care provider that are necessary for conducting the independent review.

          N. The parties shall be bound by an independent review organization's decision.

          O. If an independent review organization overturns the health insurer's determination to rescind a prior authorization exemption, the health insurer shall not attempt to rescind that exemption until the beginning of the next evaluation period.

          P. If an independent review organization affirms the health insurer's determination to rescind a prior authorization exemption:

                (1) the health insurer shall not retroactively deny any prior authorization granted on the basis of a rescission of a prior authorization exemption; and

                (2) a health care provider shall be eligible to apply for a new prior authorization exemption during the evaluation period that follows the evaluation period that formed the basis of the rescission."

     SECTION 3. EFFECTIVE DATE.--The effective date of the provisions of this act is January 1, 2026.

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