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It captures priority and frequency requests, enrollee demographics, ordering and rendering provider information, and the requested course of treatment or procedure. The form includes coding fields for diagnosis and procedure services, request frequency and quantity, and dedicated prescription drug sections such as dosing schedule, route, medication start timing, and formulary or step-therapy rationale. An attestation confirms information accuracy for authorization processing.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/new-mexico-uniform-prior-authorization-form/283953/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/new-mexico-uniform-prior-authorization-form/283953.png","ImageObject",442,249,{"name":88,"@type":89},"Putri","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":15},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How does the form indicate whether a request is standard or urgent/expedited?","Question",{"text":108,"@type":109},"Section 1 provides checkboxes for Standard services scheduled for the date and Urgent/Expedited requests, including provider certification that standard timing may seriously jeopardize the enrollee’s life or health.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information is required in the provider section?",{"text":113,"@type":109},"Section 3 collects ordering and/or rendering provider selection, provider name, type/specialty, administrative contact, NPI, DEA if applicable, facility details, and phone/facsimile/email contact information.",{"name":115,"@type":106,"acceptedAnswer":116},"What specific fields are included for prescription drug requests?",{"text":117,"@type":109},"Section 7 requests diagnosis name and code, patient height/weight if required, route of administration and administered setting, medication requested, strength and dosing schedule, monthly quantity or limits, current use status, medication start date, and clinical rationales including formulary or step-therapy exception reasons.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283953,1791585620,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":15,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},962085571259,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","| New Mexico Uniform Prior Authorization Form |  |  |  |\n| --- | --- | --- | --- |\n| To file electronically, attach [form:](form: www.UHCProvider.com/paan)[ ](form: www.UHCProvider.com/paan)[www.UHCProvider.com/paan](form: www.UHCProvider.com/paan) |  |  | To file via facsimile, fax to: 1-866-968-7582 |\n| To contact the coverage review team for UnitedHealthcare, please call the toll-free number on your health plan ID card between the hours of 8am to 5pm MST. For after-hours review, please contact the toll-free number on your health plan ID card. |  |  |  |\n| [1] Priority and Frequency |  |  |  |\n| a. Standard: [ ] Services scheduled for this date: I b. Urgent/Expedited [ ] Provider certifies that applying the standard review\u003Cbr>timeline may seriously jeopardize the life or health of the enrollee. |  |  |  |\n| c. Frequency: Initial [ ] Extension [ ] Previous Authorization \\#: |  |  |  |\n| [2] Enrollee Information |  |  |  |\n| a. Enrollee name: |  | b. Enrollee date of birth: | c. Subscriber/Member ID \\# : |\n| d. Enrollee street address: |  |  |  |\n| e. City: |  | f . State: | g. Zip code: |\n| [3] Provider Information: Ordering Provider [ ] Rendering Provider [ ] Both [ ]\u003Cbr>Please note: processing delays may occur if rendering provider does not have appropriate documentation of medical necessity. Ordering provider may need to initiate prior authorization. |  |  |  |\n| a. Provider name: I b. Provider type/specialty: |  |  | c. Administrative contact: |\n| d. NPI \\#: |  |  | e. DEA\\# if applicable: |\n| f. Clinic/facility name: |  |  | g. Clinic/pharmacy/facility street address: |\n| h. City , State, Zip code |  | i. Phone number and ext.: | j. Facsimile/Email: |\n| [4] Requested medical or behavioral health course of treatment/procedure/device information (skip to Section 8 if drug requested) |  |  |  |\n| a. Service description: |  |  |  |\n| b. Setting/CMS POS Code Outpatient [ ] Inpatient [ ] Home [ ] Office [ ] Other* [ ] |  |  |  |\n| c. *Please specify if other: |  |  |  |\n| [5] HCPCS/CPT/CDT/ICD-10 CODES |  |  |  |\n| a. Latest ICD-10 Code | b. HCPCS/CPT/CDT Code |  | c. Medical Reason |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n| [6] Frequency/Quantity/Repetition Request |  |  |  |\n| a. Does this service involve multiple treatments? Yes [ l No [ l If \"No,\" skip to Section 7. |  |  |  |\n| b. Type of service: |  |  | c. Name of therapy / agency: |\n| d. Units/Volume/Visits requested: I e. Frequency/length of time needed: |  |  |  |\n\n\n| [7] Prescription Drug |\n| --- |\n| a. Diagnosis name and code: |\n| b. Patient Height (if required): I c. Patient Weight (if required): |\n| d. Route of administration Oral/SL [ ] Topical [ ] Injection [ ] IV [ ] Other* [ ]\u003Cbr>*Explain if \"Other:\" |\n| e. Administered: Doctor's office [ ] Dialysis Center [ ] Home Health/Hospice [ ] By patient [ ] |\n\n\n| f. Medication Requested | g. Strength (include both loading and maintenance dosage) | h. Dosing Schedule (including length of therapy) |  | i. Quantity per month or Quantity Limits |\n| --- | --- | --- | --- | --- |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n| j. Is the patient currently treated with the requested medication[s]? Yes* [ ] No [ ]\u003Cbr>*If \" Yes,\" when was the treatment with the requested medication started? Date: |  |  |  |  |\n| k. Anticipated medication start date (MM/DD/YY}: |  |  |  |  |\n| I. General prior authorization request. Explain the clinical reason(s) for the requested medications, including an explanation for selecting these medications over alternatives: |  |  |  |  |\n| I. Rationale for drug formulary or step-therapy exception request:\u003Cbr>□ Alternate drug(s) contraindicated or previously tried, but with adverse outcome, e.g. , toxicity, allergy, or therapeutic failure, Specify below:\u003Cbr>(1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s","cbCaie2b5EHaL9jc","https://ap.wps.com/l/cbCaie2b5EHaL9jc","pdf",226984,"English","# Submission and Contact Details\n## Priority and Frequency\n## Enrollee Information\n## Provider Information\n## Requested Treatment or Procedure Information\n## Codes Required (ICD-10 and HCPCS/CPT/CDT)\n## Frequency and Quantity Request\n## Prescription Drug Details\n## Previous Services and Therapy\n## Attestation and Plan Fields","[{\"question\":\"How does the form indicate whether a request is standard or urgent/expedited?\",\"answer\":\"Section 1 provides checkboxes for Standard services scheduled for the date and Urgent/Expedited requests, including provider certification that standard timing may seriously jeopardize the enrollee’s life or health.\"},{\"question\":\"What information is required in the provider section?\",\"answer\":\"Section 3 collects ordering and/or rendering provider selection, provider name, type/specialty, administrative contact, NPI, DEA if applicable, facility details, and phone/facsimile/email contact information.\"},{\"question\":\"What specific fields are included for prescription drug requests?\",\"answer\":\"Section 7 requests diagnosis name and code, patient height/weight if required, route of administration and administered setting, medication requested, strength and dosing schedule, monthly quantity or limits, current use status, medication start date, and clinical rationales including formulary or step-therapy exception reasons.\"}]","New Mexico Uniform Prior Authorization Form | PDF",1789623446]