What are you looking for? Property & CasualtyFinancial RegulationAccredited ReinsurersFinancial StatementsFinancial Examinations Financial Examinations ArchiveFinancial and Market Conduct Examinations - ArchiveTitle Insurance Forms & TablesASR USR Schedules & InstructionsStatistical ReportsIndividuals and AgenciesContinuing Education (CE)Criminal OffenseLicense Status VerificationAnnual/Quarterly ChecklistsFraud AssessmentsCompany LicensingRenewalsStatutory DepositsFeesApplying for Admission & ApplicationsLife and Health DivisionProduct FilingPharmacy Benefit Managers (PBM) Reports, New Mexico Health Access Survey, and BriefsContracted and External ReportsOSI Health Insurance BriefsThe 2023 New Mexico Health Access SurveyResource BinderConsumer Assistance Plan Continuous Quality ImprovementCoverage for Individuals with Diabetes (HB53)Cultural and Linguistic PlanDebt Collection Protection Act - Provider ResourceDental Provider CredentialingGuidance for CarriersHealth Rate ReviewManaged Health Care Compliance DeadlinesMember GrievanceMental Health ParityMonthly Member EnrollmentNetwork AdequacyPrescription Drug Price TransparencyProvider CredentialingProvider GrievanceRequest for Confidential StatusSmall Business Health Insurance Premium Relief InitiativeUtilization ManagementVaccine Purchasing Act OSI Events Calendar View our calendar of events 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 (PDF) 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 (PDF) Uniform Prior Authorization Form Click here to access the form. (PDF) – 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 (PDF) Bulletin 2022-011 – Prior Authorization Data Call (PDF) 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 201820192020202120222023SummaryPrior Authorization Data Introduction Report (2019) (PDF)Prior Authorization Report Introduction (2020) (PDF)2023 Prior Authorization Executive Summary reportData ReportPrior 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 (PDF)Medicaid-Insurer-Prior-Authorization-Report-Calendar-Year-2023 (PDF)Commerical-Insurer-Prior-Authorization-Report-Calendar-Year-2023_All-Carriers (PDF)
