New Mexico Health Care Authority Prior Authorization Lookup
- New Mexico Health Care Authority timely filing
- New Mexico Health Care Authority coverage criteria
- All New Mexico Health Care Authority policy updates
Latest New Mexico Health Care Authority prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2024-10-01Orthodontic Medical Necessity CriteriaDefines medical necessity, documentation, provider eligibility, billing, and prior authorization requirements for orthodontic treatment for eligible New Mexico Medicaid members under age 21. Affects Turquoise Care MCOs and dental providers billing Medicaid.All New Mexico Health Care Authority updates
- Prior AuthReimbursement/Payment PolicyEff. 2024-07-01Ambulatory Surgical Center Services — Reimbursement and CoverageState Medicaid rules governing eligibility, covered and noncovered services, utilization review, prior authorization, and reimbursement methodology for ambulatory surgical centers participating in New Mexico Medicaid.All New Mexico Health Care Authority updates
- Prior AuthReimbursement/Payment PolicyEff. 2024-07-01Medication Assisted Treatment (MAT) Medications; Narcan and NaloxoneDirects Turquoise Care Managed Care Organizations to cease prior authorization for FDA‑approved MAT drugs, outlines generic‑first policy rules, and requires reimbursement for nasal Narcan and naloxone kits including counseling incentive fees; affects MCO coverage and pharmacy reimbursement for Medicaid members.All New Mexico Health Care Authority updates
- Prior AuthAdministrative/Operational PolicyEff. 2024-07-01Nursing facility (NF) level-of-care, PASRR, and prior approval proceduresGoverns MCO and NF procedures for NF Level of Care (LOC) determinations, PASRR screening/evaluation, prior authorization submissions, reserve bed days, and related MCO-LTSSB inquiry processes for New Mexico Medicaid nursing facility placements.All New Mexico Health Care Authority updates
- Prior AuthAdministrative/Operational PolicyEff. 2024-07-01TITLE 8 SOCIAL SERVICES CHAPTER 311 – HOSPITAL SERVICES (Part 2)Rules governing Medicaid (MAD) coverage, provider eligibility, billing, utilization review, prior authorization, and reimbursement for inpatient, outpatient, and emergency hospital services in New Mexico; applies to providers and the general public.All New Mexico Health Care Authority updates
- Prior AuthAdministrative/Operational PolicyEff. 2023-08-15MCO Requirements for Coordinating Treatment Foster Care (TFC) Placements for Children in State Custody (CISC)This Letter of Direction mandates Centennial Care 2.0 MCO responsibilities for confirming medical necessity, prior authorization, coordination, documentation, and quarterly reporting when Children, Youth, and Families Department (CYFD) refers children in state custody for Treatment Foster Care (TFC). It affects New Mexico MCOs and their care coordinators who serve CISC enrollees.All New Mexico Health Care Authority updates
- Prior AuthReimbursement/Payment PolicyEff. 2022-03-14Nursing facility ventilator reimbursement add-on rateDefines reimbursement rules and per diem rate for ventilator-dependent nursing facility residents in New Mexico Medicaid, including payment amount, rate reporting, prior authorization, and clinical review requirements; affects Medicaid-enrolled nursing facilities providing ventilator services.All New Mexico Health Care Authority updates
- Prior AuthAdministrative/Operational PolicyEff. 2021-08-10Specialized behavioral health provider enrollment and reimbursementState rules governing enrollment, eligibility, coverage, supervision, utilization review, prior authorization, and reimbursement for specialized behavioral health services provided to New Mexico Medicaid (MAP) recipients.All New Mexico Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2019-10-15Applied Behavior Analysis (ABA) coverage criteria — Section A. Coverage CriteriaComments and recommendations to New Mexico Health Care Authority about Section A Coverage Criteria for Specialized Behavioral Health Services, focusing on ABA benefit eligibility, provider roles, prior authorization, age limits, and diagnosis-specific restrictions. Affects state Medicaid behavioral health policy and providers delivering ABA services in New Mexico.All New Mexico Health Care Authority updates
- Prior AuthReimbursement/Payment PolicyEff. 2019-01-01Applied Behavior Analysis (ABA) proposed fee schedule for Medicaid Fee-for-ServiceProposed ABA fee schedule and code crosswalk for New Mexico Medicaid fee-for-service, specifying codes, modifiers, allowed practitioners, unit definitions, prior authorization requirements, and proposed rates (subject to public comment). Affects providers billing ABA services to New Mexico Medicaid FFS recipients.All New Mexico Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2019-01-01Pharmacy (Centennial Care) — Coverage Criteria and HCV Treatment GuidanceDefines Centennial Care pharmacy benefit rules and Managed Care Organization (MCO) obligations for formulary management, prior authorization, Hepatitis C treatment guidance, community pharmacy reimbursement, DUR participation, drug rebate dispute resolution, and PBM oversight. Applies to MCOs administering New Mexico Centennial Care pharmacy services.All New Mexico Health Care Authority updates
- Prior AuthAdministrative/Operational PolicyEff. 2016-01-01Adult Chemical Dependency Residential Treatment Center (RTC) ServicesDefines a Value Added Service (VAS) for adults with substance use disorders providing 24-hour supervised residential detox and recovery services, eligibility, limits, and prior authorization requirements for New Mexico Medicaid and ABP members.All New Mexico Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2014-01-01HEALTH CARE PROFESSIONALS MEDICAID GENERAL BENEFIT DESCRIPTIONState rule describing Medicaid (MAD) coverage, limitations, provider requirements, and covered services for MAP eligible recipients in New Mexico; governs enrolled providers and impacts reimbursement, prior authorization, and service limits.All New Mexico Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2014-01-01Health Care Professional Services — General Benefit DescriptionState Medicaid (MAD) rules describing covered professional health care services, limits, prior authorization, and program administration for MAP eligible recipients in New Mexico.All New Mexico Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2014-01-01Health Care Professional Services — General Benefit DescriptionGoverns Medicaid (MAP) coverage, limits, and administrative requirements for medically necessary professional health care services provided to MAP eligible recipients in New Mexico; applies to providers and the general public seeking to understand covered services, limitations, and prior authorization rules.All New Mexico Health Care Authority updates
- Prior AuthAdministrative/Operational PolicyEff. 2014-01-01Nursing Facilities: Prior Authorization, PASRR, and Level-of-Care ProceduresGuidelines for managed care organizations (MCOs) and nursing facilities (NFs) on prior authorization, PASRR screening/evaluation, level-of-care (LOC) packet requirements, reserve bed days, lengths of stay, and related procedures affecting NF admissions and continued stays.All New Mexico Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2014-01-01PHARMACY SERVICES, PRESCRIBING, AND PRACTITIONER‑ADMINISTERED DRUG ITEMSState rule governing Medicaid (MAD) pharmacy services, prescribing, provider responsibilities, coverage limits, prior authorization, utilization review, and reimbursement for New Mexico MAP eligible recipients.All New Mexico Health Care Authority updates
- Prior AuthReimbursement/Payment PolicyEff. 2014-01-01Pharmacy Services, Prescribing, and Practitioner-Administered Drug ReimbursementState rule governing Medicaid (MAP) coverage, provider eligibility, provider responsibilities, coverage limits, prior authorization, utilization review, and reimbursement methods for pharmacy and practitioner-administered drug items administered by the New Mexico Medical Assistance Division (MAD). Applies to providers and MAP eligible recipients under New Mexico MAD.All New Mexico Health Care Authority updates
- Prior AuthAdministrative/Operational PolicyEff. 2014-01-01Provider responsibilities and requirements for transportation services and lodging (MAD)Governs provider responsibilities, eligible providers, covered transportation, lodging, meal and attendant services, prior authorization, utilization review, and reimbursement rules for New Mexico medical assistance (MAD) transportation and related services; applies to providers furnishing services to MAP eligible recipients.All New Mexico Health Care Authority updates
- Prior AuthAdministrative/Operational PolicyEff. 2014-01-01Transportation Services and Lodging (MAD)Governs coverage, provider eligibility, responsibilities, prior authorization, utilization review, and reimbursement for transportation, lodging, meal, and attendant-related expenses for New Mexico medical assistance program (MAP) eligible recipients.All New Mexico Health Care Authority updates
- Prior AuthAdministrative/Operational PolicyEff. 2014-01-01Transportation Services and Lodging (MAD/MAP)Governs provider responsibilities, eligible providers, covered transportation-related services (transport, lodging, meals, attendants), prior authorization, utilization review, and reimbursement rules for New Mexico Medical Assistance Program (MAP) transportation services.All New Mexico Health Care Authority updates
- Prior AuthAdministrative/Operational PolicyEff. 2014-01-01Vision appliances, hearing appliances, durable medical equipment, oxygen, medical supplies, prosthetics and orthoticsThis document defines Medicaid (MAD) coverage, prior authorization, service limitations, and reimbursement rules for durable medical equipment (DME), oxygen systems, vision and hearing appliances, augmentative communication devices, prosthetics and orthotics for MAP eligible recipients.All New Mexico Health Care Authority updates
- Prior AuthAdministrative/Operational PolicyEff. 2008-08-01COORDINATED LONG TERM SERVICES CLIENT TRANSITION OF CAREPolicy governing continuity and transition procedures for Medicaid members enrolled in the New Mexico Coordinated Long-Term Services (CoLTS) managed care and the statewide entity (SE), including responsibilities for service continuity, prior authorizations, payment, and claims processing.All New Mexico Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2005-07-01STATE COVERAGE INSURANCE (SCI) BENEFIT PACKAGEDefines the SCI benefit package services, limitations, prior authorization requirements, and coverage rules for members and MCOs under New Mexico's SCI program. Applies to the general public and managed care organizations administering SCI benefits.All New Mexico Health Care Authority updates
- Prior AuthAdministrative/Operational PolicyEff. 2001-07-01Medicaid Managed Care Client Transition of CareState rule governing transition-of-care policies, prior authorizations, provider payments, and claims responsibilities for New Mexico Medicaid managed care organizations (MCO), the state enrollment (SE), CoLTS, and HSD; applies to the general public and Medicaid-eligible members moving between coverage types or care settings.All New Mexico Health Care Authority updates
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Tool Description
Search New Mexico Health Care Authorityprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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