{"data":{"id":"us-nm/59a-22b-2","jurisdiction":"us-nm","citation":"59A-22B-2","heading":"Definitions.","body":"As used in the Prior Authorization Act:\nA. \"adjudicate\" means to approve or deny a request for prior authorization;\nB. \"auto-adjudicate\" means to use technology and automation to make a near-real-time determination to approve, deny or pend a request for prior authorization;\nC. \"chronic health condition\" means a condition that lasts one or more years and requires ongoing medical attention or limits activities of daily living;\nD. \"chronic maintenance drug\" means a medication approved by the federal food and drug administration to be taken regularly for the treatment of chronic health conditions;\nE. \"covered person\" means an individual who is insured under a health benefits plan;\nF. \"emergency care\" means medical care, pharmaceutical benefits or related benefits to a covered person after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could be reasonably expected by a reasonable layperson to result in jeopardy to a person's health, serious impairment of bodily functions, serious dysfunction of a bodily organ or part or disfigurement to a person;\nG. \"health benefits plan\" means a policy, contract, certificate or agreement, entered into, offered or issued by a health insurer to provide, deliver, arrange for, pay for or reimburse any of the costs of medical care, pharmaceutical benefits or related benefits;\nH. \"health care professional\" means an individual who is licensed or otherwise authorized by the state to provide health care services;\nI. \"health care provider\" means a health care professional, corporation, organization, facility or institution licensed or otherwise authorized by the state to provide health care services;\nJ. \"health insurer\" means a health maintenance organization, nonprofit health care plan, provider service network, medicaid managed care organization or third-party payer or its agent;\nK. \"medical care, pharmaceutical benefits or related benefits\" means medical, behavioral, hospital, surgical, physical rehabilitation and home health services, and includes pharmaceuticals, durable medical equipment, prosthetics, orthotics and supplies;\nL. \"medical necessity\" means health care services determined by a health care provider, in consultation with the health insurer, to be appropriate or necessary according to:\n(1) applicable, generally accepted principles and practices of good medical care;\n(2) practice guidelines developed by the federal government or national or professional medical societies, boards or associations; or\n(3) applicable clinical protocols or practice guidelines developed by the health insurer consistent with federal, national and professional practice guidelines, which shall apply to the diagnosis, direct care and treatment of a physical or behavioral health condition, illness, injury or disease;\nM. \"medical peer review\" means review by a health care professional from the same or similar practice specialty that typically manages the medical condition, procedure or treatment under review for prior authorization;\nN. \"off-label\" means a federal food and drug administration-approved medication that does not have a federal food and drug administration-approved indication for a specific condition or disease but is prescribed to a covered person because there is sufficient clinical evidence for a prescribing clinician to reasonably consider the medication to be medically necessary to treat the covered person's condition or disease;\nO. \"office\" means the office of superintendent of insurance;\nP. \"pend\" means to hold a prior authorization request for further clinical review;\nQ. \"pharmacy benefits manager\" means a person licensed by the superintendent as a pharmacy benefits manager pursuant to the provisions of the Pharmacy Benefits Manager Regulation Act [Chapter 59A, Article 61 NMSA 1978] that has a direct contract with an entity subject to the Health Care Purchasing Act [Chapter 13, Article 7 NMSA 1978];\nR. \"prior authorization\" means a voluntary or mandatory pre-service determination, including a recommended clinical review, that a health insurer makes regarding a covered person's eligibility for health care services, based on medical necessity, the appropriateness of the site of services and the terms of the covered person's health benefits plan;\nS. \"rare disease or condition\" means a disease or condition that affects fewer than two hundred thousand people in the United States; and\nT. \"serious mental illness\" means a mental condition that significantly impairs daily functioning and requires comprehensive treatment. \"Serious mental illness\" includes major depression, schizophrenia, schizoaffective disorder, bipolar disorder, obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder and borderline personality disorder.","path":["Chapter 59A - Insurance Code","ARTICLE 22B Prior Authorization"],"source_url":"https://nmonesource.com/nmos/nmsa-unanno/en/item/18562/index.do","current_through":"2026-07-01","vintage":"","retrieved_at":"2026-09-03T15:02:20Z","sha256":"00203b7e3f87e8984694ee033e8345b60435d3ac006010ffb904d06125f7c46c","source_id":"us-nm","stale":false,"prev":"us-nm/59a-22b-1","next":"us-nm/59a-22b-3"},"notice":"GroundRules: Original legal text. Not legal advice."}