How Prior Authorization (PA) Works
Prior authorization (PA) is part of True Health New Mexico’s utilization management (UM) process. UM, also called utilization review, is the evaluation of the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities under the provisions of your health plan.
What Services Require PA?
Most routine services, such as a visit with a PCP or specialist, do not need a PA. You usually need a PA for certain procedures or surgeries, exceptions to the formulary (drug list), and requests for services outside of our provider network. Customer Service also can tell you which services require PA.
PA for In-Network Care
When an in-network provider recommends care that requires a PA, the provider is responsible for contacting True Health New Mexico. The provider must submit information about your condition so we can review and determine whether the requested service is covered by your plan, and if so, if it is medically necessary. We may need to talk to your provider about the request.
You may also submit a PA request to True Health New Mexico on your own behalf. You may choose to work with your provider to gather the information that will be needed or call Customer Service for help.
PA for Out-of-Network Care
Services provided by an out-of-network provider, except for emergency services and urgent care, require that your in-network provider request and get PA from our Medical Management team before services are received. Services from an out-of-network provider will not be covered unless this PA is obtained before receiving the services. You may be liable for the charges resulting from failure to obtain PA for services provided by the out-of-network provider.
To ensure that your PA is in place, call Customer Service at 1-844-508-4677 before your scheduled service.
If you are admitted to a hospital, the facility must tell True Health New Mexico. It is up to you and your provider to see that all PA procedures outlined by True Health New Mexico are followed correctly. These procedures are in your Evidence of Coverage/Member Handbook.
How We Review PA Requests
When a PA is required, True Health New Mexico uses doctors who are licensed in New Mexico to conduct the reviews and to make determinations (decisions).
True Health New Mexico nurses review all inpatient services as they occur to ensure that you are receiving the best service for your level of care.
Learn More about Our Medical Management Services and Processes
- We offer case management services to True Health New Mexico members who have complex healthcare needs. This ensures that you receive appropriate and timely care.
- We also offer transition-of-care (TOC) services for up to 30 days. These services are for when you are being treated by a non-contracted provider at the time of your True Health New Mexico enrollment. Learn more about TOC services at the case management link above.
- You can find complete PA and UM information in your Evidence of Coverage/Member Handbook. To find the Handbook for your plan, visit our Member Forms page and click the button that corresponds to your type of plan (individual/family, small group, or large group).