New Mexico 2025 Regular Session

New Mexico Senate Bill SB263 Compare Versions

Only one version of the bill is available at this time.

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28	28	SENATE BILL 263
29	29	57
30	30	TH LEGISLATURE
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33	33	STATE
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35	35	OF
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39	39	MEXICO
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42	42	FIRST SESSION
43	43	,
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45	45	2025
46	46	INTRODUCED BY
47	47	Martin Hickey
48	48	AN ACT
49	49	RELATING TO INSURANCE; ENACTING A NEW SECTION OF THE PRIOR
50	50	AUTHORIZATION ACT TO REQUIRE HEALTH INSURERS TO ESTABLISH
51	51	PROCEDURES TO GRANT EXEMPTIONS FROM THEIR PRIOR AUTHORIZATION
52	52	PROCESS FOR HEALTH CARE PROVIDERS THAT MEET CERTAIN CRITERIA.
53	53	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
54	54	SECTION 1. Section 59A-22B-1 NMSA 1978 (being Laws 2019,
55	55	Chapter 187, Section 3) is amended to read:
56	56	"59A-22B-1. SHORT TITLE.--[Sections 3 through 7 of this
57	57	act] Chapter 59A, Article 22B NMSA 1978 may be cited as the
58	58	"Prior Authorization Act"."
59	59	SECTION 2. A new section of the Prior Authorization Act
60	60	is enacted to read:
61	61	"[NEW MATERIAL] PROCESS FOR GRANTING EXEMPTIONS FROM PRIOR
62	62	AUTHORIZATION PROCESS CREATED--APPLICATIONS--ELIGIBILITY--
63	63	.228814.3 underscored material = new
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90	90	RESCISSION--INDEPENDENT REVIEW.--
91	91	A. For purposes of this section, "evaluation
92	92	period" means a six-month period beginning each January and
93	93	each June.
94	94	B. A health care provider may apply to a health
95	95	insurer for an exemption from its prior authorization process
96	96	for a health care service. A health insurer shall grant the
97	97	exemption request if, in the evaluation period prior to the
98	98	exemption request, no less than ninety percent of the health
99	99	care provider's prior authorization requests for that health
100	100	care service have been approved upon initial submission or
101	101	after appeal.
102	102	C. A health insurer shall provide a written
103	103	approval or denial of the prior authorization exemption request
104	104	no later than ten business days after receipt of the request.
105	105	D. When a health care provider's prior
106	106	authorization exemption request is denied, a health insurer
107	107	shall provide an explanation for the denial, including data,
108	108	that sufficiently demonstrates how the request failed to meet
109	109	the criteria established pursuant to Subsection A of this
110	110	section.
111	111	E. When a health care provider's prior
112	112	authorization exemption request is approved, a health insurer
113	113	shall provide the health care provider with information
114	114	regarding the rights and obligations of the parties, including
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143	143	the effective date of the prior authorization exemption.
144	144	F. Once, during each evaluation period, a health
145	145	insurer may determine whether to continue or rescind a health
146	146	care provider's prior authorization exemption.
147	147	G. A health insurer shall not rescind a health care
148	148	provider's prior authorization exemption unless the health
149	149	insurer:
150	150	(1) determines that less than ninety percent
151	151	of the claims submitted by the health care provider during the
152	152	previous evaluation period would have met the applicable
153	153	medical necessity criteria, based on a retrospective review of
154	154	a random sample of not fewer than five but no more than twenty
155	155	claims; and
156	156	(2) provides the health care provider with
157	157	written notice not less than twenty-five days before the
158	158	rescission is to take effect, including an explanation and the
159	159	sample information used to make the determination.
160	160	H. A health care provider has a right to a request
161	161	an independent review of the determination to rescind a prior
162	162	authorization exemption.
163	163	I. A health insurer shall not require a health care
164	164	provider to engage in an internal appeal process before
165	165	requesting an independent review of the determination to
166	166	rescind a prior authorization exemption.
167	167	J. An independent review organization shall
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196	196	complete a review of an adverse determination no later than
197	197	thirty days after the date a health care provider files a
198	198	request for the review.
199	199	K. A health care provider may request that the
200	200	independent review organization conduct a review of another
201	201	sample of claims using the process described in Subsection G of
202	202	this section.
203	203	L. The independent review shall be conducted by a
204	204	person licensed to practice medicine in this state. If the
205	205	rescission applies to a physician, the determination shall be
206	206	made by a person licensed to practice medicine in this state
207	207	who practices in the same or similar specialty as the physician
208	208	requesting the review.
209	209	M. The health insurer shall pay:
210	210	(1) for an independent review of the adverse
211	211	determination; and
212	212	(2) a reasonable fee, determined by the New
213	213	Mexico medical board, for any copies of medical records or
214	214	other documents requested from the health care provider that
215	215	are necessary for conducting the independent review.
216	216	N. The parties shall be bound by an independent
217	217	review organization's decision.
218	218	O. If an independent review organization overturns
219	219	the health insurer's determination to rescind a prior
220	220	authorization exemption, the health insurer shall not attempt
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249	249	to rescind that exemption until the beginning of the next
250	250	evaluation period.
251	251	P. If an independent review organization affirms
252	252	the health insurer's determination to rescind a prior
253	253	authorization exemption:
254	254	(1) the health insurer shall not retroactively
255	255	deny any prior authorization granted on the basis of a
256	256	rescission of a prior authorization exemption; and
257	257	(2) a health care provider shall be eligible
258	258	to apply for a new prior authorization exemption during the
259	259	evaluation period that follows the evaluation period that
260	260	formed the basis of the rescission."
261	261	SECTION 3. EFFECTIVE DATE.--The effective date of the
262	262	provisions of this act is January 1, 2026.
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