Utilization Management

Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization or step-therapy protocols that allow payers, particularly health insurance companies, to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. OSI regulates the utilization management practices of health insurers. 

Utilization Management Guidance Chart and Resources

• Utilization Management Guidance Chart v1
• Know your rights Endorsement
• Prior Authorization Flow Chart

Reporting Templates

• UM Section 5 Workbook Determinations v1
• UM Section 2 Workbook Scope v1
• Utilization Management Attestation v1
• Gold Card Reporting Guidance and Requirements – Updated July 12, 2023
• Commercial Prior Authorization Data Call template v3 – Updated October 2026
• Medicaid Prior Authorization Data Call template

Frequently Asked Questions (FAQs)

• NM OSI Utilization Management Carrier FAQs v1 2026

Uniform Prior Authorization Form

• Click here to access the form. – Updated January 9, 2025

Prior Authorization Required Plan language

• STANDARD LANGUAGE, ADMINISTRATIVE DATA AND DISCONTINUATION NOTICES – NM OSI

Rules

• 13.10.17, 13.10.22.9, 13.10.31 NMAC

News, Bulletins, and Orders

• Bulletin 2025-001 – Request for Alternative Prior Authorization Form
• Bulletin 2022-011 – Prior Authorization Data Call
• Bulletin 2023-020 – Gold Carding Data Call

Apply for TPA License

• NIPR

Consumer Resources

• File a complaint about issues with prior authorization, step-therapy and drug formulary exceptions requests here

Utilization Review

• Prior Authorization Data Calls and Reports

	2018	2019	2020	2021	2022	2023
Summary		Prior Authorization Data Introduction Report (2019)	Prior Authorization Report Introduction (2020)			2023 Prior Authorization Executive Summary report
Data Report	Prior Authorization Data Call Report (2018)	Prior Authorization Data Call Report (2019)	Prior Authorization Data Call Report (2020)	Prior Authorization Data Call Report (2021)	Prior Authorization Data Call Report (2022)	IBAC-Insurer-Prior-Authorization-Report-Calendar-Year-2023
						Medicaid-Insurer-Prior-Authorization-Report-Calendar-Year-2023
						Commerical-Insurer-Prior-Authorization-Report-Calendar-Year-2023_All-Carriers