HB302 amends New Mexico’s Prior Authorization Act to create a formal process allowing certain participating health care professionals to obtain exemptions from a health insurer’s prior authorization requirements for outpatient health care services. A professional may apply after each six-month evaluation period, and an insurer must grant the exemption if at least 90% of that professional’s prior authorization requests for the relevant service were approved on initial submission or after appeal during the prior evaluation period, provided there were at least 10 requests. The bill excludes pharmaceutical services and prescription drugs from the exemption process.
The bill also sets timelines and procedures for insurers to approve or deny exemption requests, explain denials, and notify providers of the terms of an approved exemption. It allows insurers to periodically review whether an exemption should continue, but limits rescission unless retrospective review shows the provider no longer meets the 90% standard. The bill creates a separate immediate rescission process for fraud or abuse, and gives providers the right to an independent review by a licensed physician, with the insurer paying review costs and related record fees. The superintendent of insurance must adopt implementing rules by December 31, 2026.
Impact
HB302 would add a new provider-facing exemption mechanism to New Mexico insurance law, changing how prior authorization is administered for outpatient services under the Prior Authorization Act. It would require health insurers to track approval rates, process exemption applications, issue written determinations, and support independent review procedures, while also limiting when exemptions can be rescinded and how retroactive denials may be handled. The bill affects health insurers, participating health care professionals, and patients who may experience fewer prior authorization delays when treated by providers who qualify for exemptions.
Sentiment
Based on the bill text and the absence of recorded committee debate or votes in the provided materials, the overall sentiment appears supportive of reducing administrative burden in health care delivery while preserving insurer oversight for medical necessity, fraud, and abuse. The structure of the bill suggests a policy compromise: easing prior authorization for high-performing providers, but retaining insurer authority to monitor compliance and rescind exemptions when standards are not met. No formal opposition or recorded controversy is available in the provided context.
Contention
The main points of contention likely involve the balance between reducing prior authorization burdens and preserving insurer controls over utilization and cost management. Insurers may be concerned about losing prior authorization oversight for providers with exemptions, while health care professionals are likely to support the bill’s streamlined process and appeal rights. Another possible area of dispute is the fraud-or-abuse standard, because it allows immediate retroactive rescission, and the independent review process may be viewed as either an important safeguard for providers or an added administrative requirement for insurers.