Superintendent of Insurance urges consumers to understand role in prior authorization process

The New Mexico Office of Superintendent of Insurance urges all health insurance consumers to actively monitor the status of any prior authorization requests submitted on their behalf.

Prior authorization is your health insurance company’s review of a request for medication, procedure, or specialist visits before you get care, according to a news release. Sometimes prior authorization is required, and sometimes it is optional; either way, it may affect whether your care is covered.

The insurer looks at whether the service is medically necessary, whether it is being done in the right setting (like a clinic versus a hospital), and whether it is covered under your health plan.

Checking ahead and staying informed can help avoid delays, denials, or unexpected costs. New Mexico law places time limitations on the review of prior authorization requests upon health insurance companies, the release stated.

The prior authorization process In some cases, medical providers or consumers may initiate a recommended clinical review, which is a voluntary form of prior authorization. While not required, this review can still affect health insurance coverage decisions, and it is important for consumers to actively check whether a prior authorization or recommended clinical review request is in process related to your health care. Taking a proactive role - by asking medical providers and health insurers about the status of any prior authorization process or recommended clinical reviews - will help prevent unexpected medical costs or interruptions in necessary health care.

“When consumers receive clear, timely information from everyone involved in their care, they are empowered to make confident decisions that support their health and well-being,” said Superintendent of Insurance Alice Kane.

Consumers of health insurance should be “informed consumers” Consumers are advised to maintain regular communication with their medical provider using agreed-upon methods (such as phone, email or patient portals) to confirm whether documentation regarding their prior authorization has been submitted and to understand where the request stands in the review process that is required to be followed by the health insurance company.

In addition, consumers should contact their health insurance company to confirm whether a prior authorization request has been submitted on their behalf and to learn how to track its progress. These reviews must follow strict timelines: Insurers have up to seven business days to decide on standard prior authorization requests, and just 24 hours for emergencies where a delay could be harmful.

Knowing whether a request has been approved or denied - and understanding your appeal options if it is denied - can help avoid treatment delays and unexpected costs.

Most health insurance companies provide this information through patient portals or other online tools. Consumers should become informed about where they may easily access information about prior authorization.

When consumers actively check in with both their health care providers and their health insurance company, they can help avoid delays and make sure they get the care they need when they need it.

For more information on prior authorization guidelines and consumer protections, visit osi.state.nm.us/ en/news/updated-bulle tin-2025-005.