Presbyterian Health Plan of New Mexico
Prior authorization requirements
New Mexico prior authorization requirements and clinical criteria
Magellan Healthcare acting on behalf of the Health Plan must make an authorization or non-authorization determination within the timeframes indicated in the Presbyterian Prior Authorization Guide (PDF) (NM ST § 59A-22B-5).
Find any written clinical guidelines at MagellanProvider.com/ClinicalGuidelines.
Find any written medical necessity criteria at MagellanProvider.com/MNC.
For Presbyterian Health Plan, Inc. and Presbyterian Insurance Company, Inc. only:
Presbyterian utilizes the Uniform Prior Authorization Form pursuant to the New Mexico Administrative Code (NMAC) 13.10.31.10.
Providers need prior authorization before the services begin. They will also need prior authorization for any of the services to continue. A carrier may remove a prior authorization requirement at any time. A carrier who removes a prior authorization requirement during a plan year shall notify its network providers of the change as soon as practicable, and no more than 60 days after the requirement is removed.
When asking Magellan to authorize services, the provider must complete an assessment and share information including:
- Diagnosis
- Current symptoms
- Events that led to an admission
- Thoughts of self-harm or harm to others
- Level of function and the impact on daily living
- Medical and behavioral health history
- Alcohol and/or drug use and any treatments
- Current medicines
- Treatment plan while getting care
- Discharge plans, including coordination of care with providers
Once Magellan receives the clinical information from the provider, we will use the clinical care guidelines below to make a determination:
- Magellan Healthcare proprietary guidelines
- Milliman Care Guidelines (MCG)
Magellan will respond to the requesting provider based on the urgency of the request.
Utilization management policies