N.M. Admin. Code § 8.325.2.15 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW

All medicaid 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 medicaid. Providers must verify that individuals are eligible for medicaid at the time services are furnished and determine if medicaid 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 8.350.2 NMAC, Reconsideration of Utilization Review Decisions.

Notes

N.M. Admin. Code § 8.325.2.15

2/1/95; 8.325.2.15 NMAC - Rn, 8 NMAC 4.MAD.761.5 & A, 11/1/04, Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024