New Mexico Statutes Chapter 59A. Insurance Code § 59A-22B-2. Definitions

A. “adjudicate” means to approve or deny a request for prior authorization;

B. “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;

C. “chronic health condition” means a condition that lasts one or more years and requires ongoing medical attention or limits activities of daily living;

D. “chronic maintenance drug” means a medication approved by the federal food and drug administration to be taken regularly for the treatment of chronic health conditions;

E. “covered person” means an individual who is insured under a health benefits plan;

F. “emergency care” means medical care, pharmaceutical benefits or related benefits to a covered person after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could be reasonably expected by a reasonable layperson to result in jeopardy to a person's health, serious impairment of bodily functions, serious dysfunction of a bodily organ or part or disfigurement to a person;

G. “health benefits plan” means a policy, contract, certificate or agreement, entered into, offered or issued by a health insurer to provide, deliver, arrange for, pay for or reimburse any of the costs of medical care, pharmaceutical benefits or related benefits;

H. “health care professional” means an individual who is licensed or otherwise authorized by the state to provide health care services;

I. “health care provider” means a health care professional, corporation, organization, facility or institution licensed or otherwise authorized by the state to provide health care services;

J. “health insurer” means a health maintenance organization, nonprofit health care plan, provider service network, medicaid managed care organization or third-party payer or its agent;

K. “medical care, pharmaceutical benefits or related benefits” means medical, behavioral, hospital, surgical, physical rehabilitation and home health services, and includes pharmaceuticals, durable medical equipment, prosthetics, orthotics and supplies;

L. “medical necessity” means health care services determined by a health care provider, in consultation with the health insurer, to be appropriate or necessary according to:

M. “medical peer review” means review by a health care professional from the same or similar practice specialty that typically manages the medical condition, procedure or treatment under review for prior authorization;

N. “off-label” means a federal food and drug administration-approved medication that does not have a federal food and drug administration-approved indication for a specific condition or disease but is prescribed to a covered person because there is sufficient clinical evidence for a prescribing clinician to reasonably consider the medication to be medically necessary to treat the covered person's condition or disease;

O. “office” means the office of superintendent of insurance;

P. “pend” means to hold a prior authorization request for further clinical review;

Q. “pharmacy benefits manager” means a person licensed by the superintendent as a pharmacy benefits manager pursuant to the provisions of the Pharmacy Benefits Manager Regulation Act that has a direct contract with an entity subject to the Health Care Purchasing Act;

R. “prior authorization” means a voluntary or mandatory pre-service determination, including a recommended clinical review, that a health insurer makes regarding a covered person's eligibility for health care services, based on medical necessity, the appropriateness of the site of services and the terms of the covered person's health benefits plan;

S. “rare disease or condition” means a disease or condition that affects fewer than two hundred thousand people in the United States;  and

T. “serious mental illness” means a mental condition that significantly impairs daily functioning and requires comprehensive treatment.  “Serious mental illness” includes major depression, schizophrenia, schizoaffective disorder, bipolar disorder, obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder and borderline personality disorder.