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SENATE BILL 263
57
TH 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--
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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
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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
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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
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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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