N.M. Admin. Code § 8.313.2.19

Current through Register Vol. 36, No. 1, January 14, 2025

Section 8.313.2.19 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW

All HCA/MAD program services are subject to utilization review for medical necessity and program compliance. Reviews can be performed before services are furnished, after services are furnished and before payment is made, or after payment is made. See 8.302.5 NMAC, Prior Authorization and Utilization Review. Once enrolled, providers receive instructions and documentation forms necessary for prior authorization and claims processing.

A. Prior authorization: Certain procedures or services can require prior authorization from MAD or its designee. Services for which prior authorization was obtained remain subject to utilization review at any point in the payment process.

B. Eligibility determination: Prior authorization of services does not guarantee that individuals are eligible for HCA/ MAD programs. Providers must verify that individuals are eligible for HCA/MAD programs at the time services are furnished and determine if HCA/MAD program recipients have other health insurance.

C. Reconsideration: Providers who disagree with prior authorization request denials or other review decisions can request a rereview and a reconsideration. See Section MAD-953, Reconsideration Of Utilization Review Decisions.

N.M. Admin. Code § 8.313.2.19

2-1-95; 8.313.2.19 NMAC - Rn, 8 NMAC 4.MAD.732.9, 11-1-00; A, 5-1-07, Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024