Utilization Management Process
The NMHC Medical Management Team evaluates requests for coverage in order to ensure that services rendered to members are medically necessary and/or appropriate, are occurring in the appropriate setting, and are included in the member’s benefit coverage. We utilize nationally recognized criteria (including InterQual®), evidence-based guidelines, and NMHC medical policies for clinical decision making. Utilization Management encompasses services rendered in ambulatory, inpatient, and transitional settings.
Upon request, NMHC will provide a copy of the clinical rationale and medical criteria used to make a determination. There is no charge for this request. To obtain a copy, you may call our Medical Management Department at 1-855-769-6642, option 3, Monday through Friday, between 8:00 a.m. and 5:00 p.m., Mountain Time, or send a written request to: New Mexico Health Connections, P.O. Box 17874, Austin, TX 78760.
If you have questions, you may call the plan’s pharmacy benefit manager customer support at 1-855-577-6550, Monday through Friday, between 8:00 a.m. and 5:00 p.m., Mountain Time.
The link below is to a compressed (zipped) file that contains the clinical rationale and pharmacy criteria sets used to make medication determinations. For questions, you may call the plan's pharmacy benefit manager customer support at 855-769-6642, Monday through Friday, between 8:00 a.m. and 5:00 p.m., Mountain Time.
Zipped file of pharmacy criteria sets – updated January 2017
Prior authorization is the process of reviewing a requested medical service or item to determine if it is medically necessary and covered under the member’s plan. Prior authorization is part of the utilization management process and case management model. Determinations for medical appropriateness are made by evaluating information from the requesting physician, the member’s medical records, consultations, and relevant laboratory and radiological information.
NMHC requires prior authorization for all elective hospitalizations, transfers to non-participating facilities, skilled nursing facility admissions, acute rehabilitation facility admissions, and advanced radiology services (CT, MRI, and PET scans). Prior authorization is also required for certain ambulatory services and DME.
NMHC will make a determination for services where a prior authorization is required and will notify the member and the provider of the determination by phone and in writing. A standard (non-urgent) determination regarding prescription drugs will be made within three (3) working days, and five (5) working days for all other services of the receipt of request.
Please refer to the Prior Authorization List for a complete list of services that require prior authorization.
Concurrent review is an extension of a previously approved ongoing course of treatment over a period of time or number of treatments. NMHC will make a determination if a concurrent approval is required and will notify the member and provider by phone and in writing. The determination will be made within five (5) working days of the receipt of the request.
Post-service review is any review for care or services that have already been received, e.g., retrospective review. Post-service determinations include any requests for coverage of care or service that a member has already received. Determinations will be made within thirty (30) calendar days of receipt of the request.
The expedited review will be conducted when NMHC determines, or when a provider indicates a delay would seriously jeopardize the member’s life, health or ability to attain, maintain, or regain maximum functions. The determination will be made within twenty-four (24) hours of the receipt of the request. This includes urgent pre-service and concurrent determinations.
While all requests for services that require prior or concurrent authorization will be reviewed by an appropriate clinical professional, all adverse determinations will be referred to a NMHC medical director for an adverse determination decision. Prior to a formal appeal, providers may discuss the decision with the applicable NMHC medical director who made the adverse determination, which includes a peer-to-peer conversation around the clinical evidence involved in the case.
Obtaining Authorization for Pre- and Concurrent Services
For all services that require an authorization, the provider must contact the NMHC Medical Management department at 1-855-769-6642, option 3.
Authorization requests may be phoned in to NMHC Medical Management during normal business hours, Monday through Friday, 8:00 a.m.to 5:00 p.m. MST, or faxed to 1-866-628-3047. If providers require assistance for urgent (expedited) determinations after business hours, please call 1-855-769-6642 to reach an on-call nurse case manager.
Requests for authorizations must be made before the anticipated procedure, transfer, admission, or service is provided.
Please include the following information in a Request for Authorization or for Concurrent Review for continued coverage of care:
- Member’s name and subscriber number
- Scheduled date of procedure, transfer, admission, or service
- Name of attending, referring, or ordering physician
- Location of service and rendering physician
- Supporting clinical/medical information for request
Please refer to the Prior Authorization Request Form.
For detailed information regarding determinations, please contact us at 1-855-769-6642.
Note: Due to circumstances regarding member eligibility and timeliness standards, an authorization is not a guarantee for payment. Prior authorization does not guarantee payment in cases of fraud and/or misrepresentation. Such cases may include the addition of procedures that were not originally authorized and/or information not originally provided.