N.M. Admin. Code § 8.312.2.24 - [Effective 8/1/2025] PRIOR APPROVAL AND UTILIZATION REVIEW

All MAD services are subject to utilization review for medical necessity, inspection of care, 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 8.310.2 NMAC. The provider must contact HCA or its authorized agents to request UR instructions. It is the provider's responsibility to access these instructions or ask for paper copies to be provided, to understand the information provided, to comply with the requirements, and to obtain answers to questions not covered by these materials.

A. Prior approval: Certain procedures or services can require prior approval from MAD, the MCO or their designee. Services for which prior approval was obtained remain subject to UR at any point in the payment process.

B. Eligibility determination: Prior authorization of services does not guarantee that an individual is eligible for MAD services or other health care programs. A provider must verify that an individual is eligible for a specific program at the time services are furnished and must determine if the eligible recipient or member has other health insurance.

C. Reconsideration: A provider who disagrees with a prior approval request denial or other review decisions can request a reconsideration of utilization review; see 8.350.2 NMAC.

Notes

N.M. Admin. Code § 8.312.2.24

8.312.2.24 NMAC - Rp, 8.312.2.24 NMAC, 8/1/14, Amended by New Mexico Register, Volume XXXVI, Issue 04, February 25, 2025, eff. 3/1/2025, Amended by New Mexico Register, Volume XXXVI, Issue 12, June 24, 2025, eff. 8/1/2025