Bill > SB263

This bill modifies the Prior Authorization Act to establish a process for healthcare providers to obtain exemptions from prior authorization requirements with health insurers. Under the new provisions, a healthcare provider can apply for an exemption if at least 90% of their prior authorization requests for a specific service were previously approved. The health insurer must respond to the exemption request within 10 business days and provide a detailed explanation if the request is denied. If granted, the exemption can be reviewed once per six-month evaluation period, during which the insurer may rescind the exemption only if less than 90% of the provider's claims would have met medical necessity criteria based on a random sample of claims. The bill provides healthcare providers with the right to an independent review if their exemption is rescinded, conducted by a licensed medical professional in the same specialty. The independent review organization's decision is binding, and if they overturn the insurer's rescission, the exemption remains in place until the next evaluation period. The bill will take effect on January 1, 2026, and aims to streamline the prior authorization process and reduce administrative burdens for healthcare providers.

Health and Social Services

https://www.nmlegis.gov/Legislation/Legislation?chamber=S&legtype=B&legno=263&year=25