PRIOR AUTHORIZATION PROCESS EXEMPTIONS

HB 461 would require New Mexico health insurers to establish a process allowing qualified health care professionals (like doctors and specialists) to bypass prior authorization for outpatient services. To qualify, a professional must have at least 90% of their prior authorization requests approved in the previous six-month period (an "evaluation period"). Insurers must grant exemptions within 10 business days if criteria are met, and can only rescind exemptions after reviewing a random sample of 5-20 claims and providing 25 days' notice, unless fraud or abuse is suspected. Health care professionals denied or having exemptions rescinded can request an independent review by a licensed physician within 30 days, with insurers covering review costs.