CurrentOptumPolicy N/A

New Mexico Uniform Prior Authorization Form

Standard prior authorization request form governing submission of medical, behavioral health, and prescription drug prior authorization requests for members in New Mexico; applies to ordering and rendering providers completing authorization requests.

Policy Summary

PayerOptum

PolicyNew Mexico Uniform Prior Authorization Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the New Mexico Uniform Prior Authorization Form including priority/frequency, enrollee and provider information, requested service or drug details, clinical rationale, prior therapies and attestations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NMstate

9form sections

1-877-235-9905fax for submissions

HCPCS/CPT/CDT/ICD-10code types

Required Submission Elements

Information to be provided to support coverage evaluation:

ALL of the following

Enrollee identification: name, date of birth, subscriber/member ID, and contact/address information (Section 2).
Priority/frequency designation: indicate Standard or Urgent/Expedited and, if expedited, include provider certification that standard timelines would jeopardize life or health (Section 1).
Requested service details: service description and setting/CMS POS code (outpatient, inpatient, home, office, other) (Section 4).
Diagnosis and procedure coding: latest ICD-10 diagnosis code and applicable HCPCS/CPT/CDT code(s), with medical reason (Coding section).

Policy Summary

PayerOptum

PolicyNew Mexico Uniform Prior Authorization Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Submitting Prior Authorization Requests

Prior Authorization

Prior Authorization Submission — Use the New Mexico Uniform Prior Authorization Form

Complete and submit the New Mexico Uniform Prior Authorization Form with priority/frequency (Standard or Urgent/Expedited), enrollee and provider information, requested service or drug details, clinical rationale, prior therapies and attestations as provided on the form.

Include enrollee name, DOB, subscriber/member ID, and contact information (see Enrollee Information).
Provide provider details (ordering/rendering), NPI, contact, and facility information.
Supply requested service or medication details, dosing, frequency, ICD-10 and HCPCS/CPT/CDT codes, and clinical rationale.
Document prior therapies, dates, and reasons for discontinuation or failure.

Prior Authorization

Expedited Review Certification — Check 'Urgent/Expedited' and Provider Certify

If applying the standard review timeline may seriously jeopardize the life or health of the enrollee, check 'Urgent/Expedited' and have the provider certify that standard timelines would jeopardize life or health.

Check the 'Urgent/Expedited' box in the Priority and Frequency section.
Ensure the provider completes the certification that standard timelines may seriously jeopardize the enrollee's life or health.

Documentation Required

Ordering vs Rendering Provider Responsibility — Who Should Initiate the Request

The ordering provider may need to initiate the prior authorization; note that processing delays can occur if the rendering provider does not have appropriate documentation of medical necessity.

Select whether the request is submitted by the Ordering Provider, Rendering Provider, or Both on the form.
Confirm the rendering provider has documentation of medical necessity to avoid delays; if not, the ordering provider should initiate the request.

Billing Rule

Submission Fax — Fax Prior Authorization to 1-877-235-9905

To file a prior authorization request via facsimile, send the completed form to 1-877-235-9905.

Include all required sections (priority/frequency, enrollee and provider information, service/drug details, clinical rationale) on the faxed form.

Key Terms and Provider Roles

inv-07: Urgent/Expedited — Definition and Threshold

DefinitionUrgent/Expedited: a request where applying the standard review timeline may seriously jeopardize the life or health of the enrollee, as certified by the provider.

How to indicateCheck the 'Urgent/Expedited' box in the Priority and Frequency section and include the provider certification that standard timelines would jeopardize life or health.

When to useFor requests requiring faster-than-standard prior authorization review because delay could seriously jeopardize the enrollee's life or health.

Related form fieldPriority and Frequency (Section 1): options for Standard or Urgent/Expedited and provider certification checkbox.

Effect on submissionMarking as Urgent/Expedited signals need for expedited review; include supporting clinical rationale in requested service or drug sections to justify urgency.

inv-08: Provider Roles — Ordering vs Rendering Responsibilities

Ordering Provider responsibilityMay need to initiate the prior authorization request; ensure the authorization is submitted with required enrollee and service information.

Rendering Provider responsibilityMust have and provide appropriate documentation of medical necessity; lack of such documentation may cause processing delays.

Form designationProvider Information section includes checkboxes for Ordering Provider, Rendering Provider, or Both, and requests NPI and contact details.

Documentation expectationInclude provider name, type/specialty, administrative contact, NPI, clinic/facility details, phone, and fax/email to support the request.

Latest ICD-10 Code	Latest ICD-10 Code
HCPCS/CPT/CDT Code	HCPCS/CPT/CDT Code

OpenPayer

New Mexico Uniform Prior Authorization Form

Required Submission Elements

Diagnosis and Procedure Codes

Submitting Prior Authorization Requests

Key Terms and Provider Roles