What is prior authorization?
Prior authorization (PA) means the health plan must approve certain care before it will cover it. Providers often submit requests for you, but you still have rights if PA is denied or delayed.
Overview: Prior authorizations. New Mexico-only details below.
Confirm plan type: New Mexico: Start Here.
New Mexico PA rules
New Mexico's Health Insurance Prior Authorization Act (NMSA 59A-22B, SB 188 and later reforms) applies to most fully insured plans regulated by OSI—not Medicare, Medicaid fee-for-service, or typical self-funded ERISA plans. OSI also adopted detailed rules in 13.10.31 NMAC.
Standard PA deadlines (NMSA 59A-22B-5)
- Standard requests: decision within 7 calendar days after the insurer receives all necessary documentation—or the PA is deemed granted
- Urgent / exigent requests: within 24 hours—or deemed granted if the insurer misses the deadline
- Carriers must accept secure electronic PA submissions 24/7 and use uniform OSI forms where required
- Approved PA must remain valid at least 60 days unless clinical criteria justify a shorter period ( 13.10.31.8 NMAC)
When PA is prohibited or limited (59A-22B-7, 59A-22B-8)
- In-network mental health and substance use disorder: carriers generally cannot require PA or referrals (59A-22B-7)
- Protected prescription drugs (plans issued or renewed on/after January 1, 2025): no PA or step therapy for FDA-approved drugs for autoimmune disorders, behavioral health conditions, cancer, or substance use disorders when no generic is available (59A-22B-8)
- Rare disease / SB 39 (plans issued on/after July 1, 2025): expanded protections for rare diseases, off-label use, and related medical necessity reviews—often 7 business days standard / 24 hours emergency with automatic approval if the insurer is late (OSI Bulletin 2025-005)
Carrier process requirements (13.10.31 NMAC)
- Tracking number and receipt confirmation within 1 business day
- Providers and members may both submit PA requests; carriers must help members complete submissions
- At least 4 hours (urgent) or 2 calendar days (standard) to supply missing information
- PA lists and criteria published on carrier websites; annual carrier reporting to OSI
OSI consumer alert on PA timelines: OSI — monitor your PA request.
Where to look up PA rules
Carriers must publish which services require PA. Use your denial letter first, then your plan's member or provider portal. OSI posts uniform PA forms at osi.state.nm.us.
Carrier links: New Mexico prior auth & internal appeals links.
Medicaid
The Prior Authorization Act does not apply the same way to Medicaid fee-for-service, but Centennial Care managed care organizations follow federal PA rules and 13.10.31 where applicable. Denials use MCO appeal and fair hearing paths—see New Mexico internal appeals.
If PA is denied
File an internal appeal with the carrier within 180 days of the adverse determination (13.10.17.12 NMAC).
Next: New Mexico internal appeals.
Urgent care
Mark PA requests urgent when delay could seriously harm the patient (59A-22B-5). The insurer must decide within 24 hours or the request is deemed granted.
Expedited internal appeals must be completed within 72 hours (13.10.17.14 NMAC).