HB 461 — PRIOR AUTHORIZATION PROCESS EXEMPTIONS

HOUSE BILL 461 5757TH THLEGISLATURE LEGISLATUR-- STATE OF NEW MEXICO - FIRST SESSIO,SESSION, 2025 INTRODUCED BY Doreen Y.

Dixon and Linda Serrato and Cristina Parajón andThis Martindocument Hickeymay 7incorporate 9amendments ANproposed ACTby RELATINGa TOcommittee, INSURANCE;but not yet adopted, as well as amendments that have been adopted during the current legislative session.

ENACTINGThe Adocument NEWis SECTIONa OFtool THEto PRIORshow AUTHORIZATIONamendments ACTin TOcontext REQUIREand HEALTHcannot INSURERSbe TOused ESTABLISHfor PROCEDURESthe TOpurpose GRANTof EXEMPTIONSadding FROMamendments THEIRto PRIORlegislation. AUTHORIZATION PROCESS FOR HEALTH CARE PROFESSIONALS THAT MEET CERTAIN CRITERIA.

eAN tACT 17h BERELATING ITTO ENACTEDINSURANCE; BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

wENACTING lA nNEW dSECTION 18OF SECTIONTHE 1.PRIOR g o t hr AUTHORIZATION ACT TO REQUIRE HEALTH INSURERS TO ESTABLISH g e i k PROCEDURES TO GRANT EXEMPTIONS FROM THEIR PRIOR AUTHORIZATION h r i s PROCESS FOR HEALTH CARE PROFESSIONALS THAT MEET CERTAIN h , t, CRITERIA.

Sectione 59A-22B-1u NMSAg 1978e (beingb Lawsl 2019,e e h n d d i = = 19o ah lBE ChapterIT 187,ENACTED SectionBY 3)THE isLEGISLATURE amendedOF toTHE read:STATE OF NEW MEXICO:

l ] b ,d i a º e rSECTION 201. "59A-22B-1.

SHORTSection TITLE.--[Sections59A-22B-1 3NMSA through1978 7(being ofLaws this2019, ar ti m= mr 21t act]e Chapterw 59A, Article 22B NMSA 1978 may be cited as the d rm ea 22n "Prioro AuthorizationChapter Act"."187, cSection e3) sis kamended 23to SECTIONread: 2.

Ad newm section: of the Prior Authorization Act e a n b 24 is enacted to read:

ub [e "[NEWd MATERIAL]s PROCESSº FORo GRANTINGt EXEMPTIONSn FROM= PRIOR.230874.1AIC .230874.1March AUTHORIZATION1, PROCESS2025 CREATED--APPLICATIONS--ELIGIBILITY--(9:29pm) RESCISSION--INDEPENDENTs REVIEW.--k A.m e e a n e d r e l u [ A d "59A-22B-1.

SHORT TITLE.--[Sections 3 through 7 of this act] Chapter 59A, Article 22B NMSA 1978 may be cited as the "Prior Authorization Act"." SECTION 2.

A new section of the Prior Authorization Act is enacted to read:

"[NEW MATERIAL ] PROCESS FOR GRANTING EXEMPTIONS FROM PRIOR AUTHORIZATION PROCESS CREATED--APPLICATIONS--ELIGIBILITY-- RESCISSION--INDEPENDENT REVIEW.-- A.

(2) "evaluation period" means a six-month h period beginning each January and each June;

and g o t hr (3) "fraud" means an intentional deception or g e i k misrepresentation made by a person with the knowledge that the h r i s deception could result in some unauthorized benefit to the h , t, person or another person and includes any act that constitutes e u g e b l e e h fraud under applicable federal or state law.

en td 17d i = = o h B.

No sooner than thirty days after the end of each w l n] db 18,d i a º e evaluation period, a participating health care professional may =r i = 19r t e w d m a ln o apply to a health insurer for an exemption from its prior id a e r 20 authorization process, including a recommended clinical review, a t m m: 21 for outpatient health care services.

Ab healthe insurer shall d rs eº 22o grantt then exemption= request.230874.1AIC if,March in1, the2025 evaluation(9:29pm) period prior c e s k 23m toe the- exemption2 request,- no less than ninety percent of the e a n be 24d healthr caree professional'sl tenu or[ moreA priord authorization uprocess, [including requestsa forrecommended thatclinical review, for outpatient health care serviceservices. have been .230874.1 - 2 - approved upon initial submission or after appeal.

HHHCº "Outpatient health care services" does not include pharmaceutical services, prescription drug products or supplies.»HHHC A health insurer shall grant the exemption request if, in the evaluation period prior to the exemption request, no less than ninety percent of the health care professional's ten or more prior authorization requests for that outpatient health care service have been approved upon initial submission or after appeal.

When a health care professional's prior authorization exemption request is denied, a health insurer shall provide an explanation for the denial, including data, that sufficiently demonstrates how the request failed to meet h the criteria established pursuant to Subsection B of this u » r section.

t h g e l i E.

When a health care professional's prior h r i s authorization exemption request is approved, a health insurer h , e h shall provide the health care professional with information t u g e b l e e , gh regarding the rights and obligations of the parties, including n d d i = = o h the effective date of the prior authorization exemption.

l ] b ,d i a º r F.

Once during each evaluation period, except as e r = t 17e w d m a n o provided for in Subsection H of this section, a health insurer w l n d 18m may: determine whether to continue or rescind a health care = = 19 a l professional's prior authorization exemption.

ib r e t º o t n = .230874.1AIC March 1, 2025 (9:29pm) s k m e - 3 - e a n e d r 20e G.l u [ A d may determine whether to continue or rescind a health care professional's prior authorization exemption.

ExceptG. as provided for in Subsection H of this a t m m 21 section, a health insurer shall not rescind a health care d r e 22 professional's prior authorization exemption unless the health c e s k 23 insurer:

eExcept aas nprovided bfor 24in (1)Subsection determinesH thatof lessthis thansection, ninetya percenthealth uinsurer [shall ofnot therescind claimsa submitted by the health care professionalprofessional's duringprior .230874.1authorization -exemption 3unless - the previoushealth evaluationinsurer: period would have met the applicable medical necessity criteria, based on a retrospective review of a random sample of not fewer than five but no more than twenty claims;

(1) determines that less than ninety percent of the claims submitted by the health care professional during the previous evaluation period would have met the applicable medical necessity criteria, based on a retrospective review of a random sample of not fewer than five but no more than twenty claims;

h H.

If a health insurer determines that a health u » r care professional has fraudulently or abusively used any t h g e l i exemption, the health insurer may immediately and retroactively h r i s to the time of the first incident of fraud or abuse rescind all h , e h exemptions upon written notice to the health care professional, t u g e b l e e , gh including an explanation and sample information used to make n d d i = = o h the determination.

l ] b ,d i a º r I.

A health care professional has a right to a e r = t 17e w d m a n o request an independent review of the determination to rescind a w l n d 18m prior: authorization exemption.

=b r e t º o t n = 19.230874.1AIC March 1, 2025 (9:29pm) s k m e - 4 - e a n e d r e l J.u [ A d prior authorization exemption.

AJ. health insurer shall not require a health care i a e r 20 professional to engage in an internal appeal process before a t m m 21 requesting an independent review of the determination to d r e 22 rescind a prior authorization exemption.

cA ehealth sinsurer kshall 23not K.require a health care professional to engage in an internal appeal process before requesting an independent review of the determination to rescind a prior authorization exemption.

AnK. independent review organization shall e a n b 24 complete a review of an adverse determination no later than u [ thirty days after the date a health care professional files a .230874.1 - 4 - request for the review.

An independent review organization shall complete a review of an adverse determination no later than thirty days after the date a health care professional files a request for the review.

If the rescission applies to a physician, the determination shall be h made by a person licensed to practice medicine in this state g o t hr who practices in the same or similar specialty as the physician g e i k requesting the review.

h r i s N.

h , t, (1) for an independent review of the adverse e u g e b l e e h determination;