A. A carrier shall, at least monthly, review and update the carrier’s utilization review process to reflect the most recent evidence and generally recognized standards of care.

Terms Used In New Mexico Statutes 59A-46-65

  • Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.

B. When performing a utilization review of mental health or substance use disorder services, including level of care placement, continued stay, transfer and discharge, a carrier shall apply criteria in accordance with generally recognized standards of care.

C. A carrier shall provide utilization review training to staff and contractors undertaking activities related to utilization review.

D. A carrier shall:

(1)     develop utilization review policies regarding quantitative and non- quantitative limitations for mental health or substance use disorder services coverage that are no more restrictive than the utilization review policies regarding quantitative and non-quantitative limitations for medical and surgical care; and

(2)     make utilization review policies available to providers or enrollees.

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