New Mexico: AI health laws

SB 188, Health Insurance Prior Authorization Act

Requires health insurers to use technology and automation to auto-adjudicate electronically transmitted prior authorization requests to approve or pend them, and requires that any auto-adjudicated request based on medical necessity that is pended or denied be reviewed by a health care professional who has knowledge of the patient's condition, or consults a specialist who does, and who makes the final determination.

Physician read. Since Jan. 1, 2021, New Mexico health insurers have had to auto-adjudicate electronically transmitted prior authorization requests, using technology and automation to make a near-real-time determination, and any auto-adjudicated request based on medical necessity that is pended or denied must be reviewed by a health care professional who has knowledge of the patient's condition or consults a specialist who does, and who makes the final determination. A denial after that review must be sent to the patient and the provider with the grounds for the denial and notice of the right to appeal.

Applies to: Health insurers subject to the Prior Authorization Act, NMSA 1978 Chapter 59A, Article 22B

Notes: Laws 2019, Chapter 187; passed the Senate March 2, 2019 and the House March 11, 2019; signed April 3, 2019. The act applies to policies entered into, offered or issued on or after July 1, 2019, required uniform prior authorization forms by Jan. 1, 2020, and required auto-adjudication of electronically transmitted requests and electronic appeals by Jan. 1, 2021, the date used. 'Auto-adjudicate' means to use technology and automation to make a near-real-time determination to approve, deny or pend a request for prior authorization (NMSA 1978 Sec. 59A-22B-2); the review rule is Sec. 59A-22B-5(E). The law predates and does not name artificial intelligence, but its auto-adjudication provisions cover automated systems. SB 20 (2026), Laws 2026, Chapter 47, signed March 6, 2026 and applying to policies entered into, offered or issued on or after Jan. 1, 2027, amends Secs. 59A-22B-2, 59A-22B-4, 59A-22B-5 and 59A-22B-8 (limits on prior authorization for certain drugs, including drugs to treat serious mental illness and chronic conditions, and coverage of certain pharmacy benefits managers) and leaves Sec. 59A-22B-5(E) unchanged.