Bill > HB461

This bill establishes a new process for health care professionals to obtain exemptions from prior authorization requirements in health insurance. Under the new law, a health care professional can apply for an exemption if at least 90% of their prior authorization requests for a specific outpatient service were approved in the previous six-month evaluation period. Health insurers must respond to exemption requests within 10 business days and provide a detailed explanation if the request is denied. Once granted, the exemption can be reviewed or potentially rescinded by the insurer only once per evaluation period, and only if less than 90% of the professional's claims would have met medical necessity criteria based on a random sample review. If an insurer attempts to rescind an exemption, the health care professional has the right to an independent medical review, which must be conducted by a licensed physician in the same or similar specialty. The independent review organization's decision is binding, and the health insurer is responsible for paying for the review. The bill includes protections against immediate rescission except in cases of fraud or abuse, and sets a timeline for implementation, with the provisions becoming effective on January 1, 2026. The goal is to streamline the prior authorization process for health care professionals who consistently demonstrate appropriate and necessary medical care.

Health and Social Services

https://www.nmlegis.gov/Legislation/Legislation?chamber=H&legtype=B&legno=461&year=25