New Mexico § 13-7-41 - Dental coverage; prior authorization

§ 13-7-41. Dental coverage; prior authorization

A. For purposes of this section, “ prior authorization ” means a written communication indicating whether a specific service is covered or

multiple services are covered and reimbursable at a specific amount, subject to applicable

coinsurance and deductibles, and issued in response to a request submitted by a provider

using a format prescribed by a dental plan. B. Group coverage, including any form of self-insurance, offered, issued or renewed

under the Health Care Purchasing Act that offers a dental plan shall provide a prior

authorization upon the submission of a properly formatted request from the insured. C. Group coverage, including any form of self-insurance, offered, issued or renewed

under the Health Care Purchasing Act that offers a dental plan shall not deny any

claim subsequently submitted for services included in a prior authorization unless

one of the following circumstances applies for each service denied: (1) benefit limitations, including annual maximums or frequency limitations, not applicable

at the time of the prior authorization, are reached due to the insured's utilization

subsequent to issuance of the prior authorization; (2) the documentation submitted for the claim clearly fails to support the claim as

originally authorized; (3) subsequent to the issuance of a prior authorization, new services are provided

to the insured or a change in the insured's condition occurs that would cause prior-authorized

services to no longer be medically necessary, based on prevailing standards of care; (4) subsequent to the issuance of a prior authorization, new services are provided

to the insured or a change in the insured's condition occurs such that the prior-authorized

procedure would at that time require disapproval pursuant to the terms and conditions

for coverage under the insured's plan in effect at the time the request for prior

authorizations was made; or (5) denial of the claim was due to one of the following reasons: (a) another entity is responsible for payment; (b) the provider has already been paid for the services identified on the claim; (c) the claim submitted was fraudulent; (d) the prior authorization was based on erroneous information provided to the dental

plan by the provider, the insured or other person; or (e) the insured was not eligible for the service on the date it was provided and the

provider did not know, or with the exercise of reasonable care, could not have known

the insured's eligibility status.