As used in the Prior Authorization Act:
A. "adjudicate" means to approve or deny a request for prior authorization;
B. "auto-adjudicate" means to use technology and automation to make a near-real-time determination to approve, deny or pend a request for prior authorization;
C. "covered person" means an individual who is insured under a health benefits plan;
D. "emergency care" means medical care, pharmaceutical benefits or related benefits to a covered person after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could be reasonably expected by a reasonable layperson to result in jeopardy to a person's health, serious impairment of bodily functions, serious dysfunction of a bodily organ or part or disfigurement to a person;
E. "health benefits plan" means a policy, contract, certificate or agreement, entered into, offered or issued by a health insurer to provide, deliver, arrange for, pay for or reimburse any of the costs of medical care, pharmaceutical benefits or related benefits;
F. "health care professional" means an individual who is licensed or otherwise authorized by the state to provide health care services;
G. "health care provider" means a health care professional, corporation, organization, facility or institution licensed or otherwise authorized by the state to provide health care services;
H. "health insurer" means a health maintenance organization, nonprofit health care plan, provider service network, medicaid managed care organization or third-party payer or its agent;
I. "medical care, pharmaceutical benefits or related benefits" means medical, behavioral, hospital, surgical, physical rehabilitation and home health services, and includes pharmaceuticals, durable medical equipment, prosthetics, orthotics and supplies;
J. "medical necessity" means health care services determined by a health care provider, in consultation with the health insurer, to be appropriate or necessary according to:
(1) applicable, generally accepted principles and practices of good medical care;
(2) practice guidelines developed by the federal government or national or professional medical societies, boards or associations; or
(3) applicable clinical protocols or practice guidelines developed by the health insurer consistent with federal, national and professional practice guidelines, which shall apply to the diagnosis, direct care and treatment of a physical or behavioral health condition, illness, injury or disease;
K. "medical peer review" means review by a health care professional from the same or similar practice specialty that typically manages the medical condition, procedure or treatment under review for prior authorization;
L. "office" means the office of superintendent of insurance;
M. "pend" means to hold a prior authorization request for further clinical review;
N. "pharmacy benefits manager" means an agent responsible for handling prescription drug benefits for a health insurer; and
O. "prior authorization" means a pre-service determination that a health insurer makes regarding a covered person's eligibility for health care services, based on medical necessity, the appropriateness of the site of services and the terms of the covered person's health benefits plan.
History: Laws 2019, ch. 187, § 4.
ANNOTATIONSCompiler's notes. — Laws 2019, ch. 187, § 4 was not enacted as part of the Insurance Code, but was compiled there for the convenience of the user.
Effective dates. — Laws 2019, ch. 187 contained no effective date provision, but, pursuant to N.M. Const., art. IV, § 23, was effective June 14, 2019, 90 days after the adjournment of the legislature.
Applicability. — Laws 2019, ch. 187, § 8 provided that the provisions of the Prior Authorization Act apply to an individual or group policy contract, certificate or agreement to provide, deliver, arrange for, pay for or reimburse any of the costs of medical care, pharmaceutical benefits or related benefits that is entered into, offered or issued by a health insurer on or after July 1, 2019, pursuant to any of the following:
A. Chapter 59A, Article 22 NMSA 1978;
B. Chapter 59A, Article 23 NMSA 1978;
C. the Health Maintenance Organization Law;
D. the Nonprofit Health Care Plan Law; or
E. the Health Care Purchasing Act.