Prior Authorization Grid

Lovelace Health Plan processes prior authorizations quickly, basing approvals on the appropriateness of care and service and the patient’s coverage. Our updated prior authorization grids reflect some important revisions.

iExchange provides a FREE, FAST, and CONVENIENT alternative to faxing or phoning in Prior Authorization requests to Lovelace Health Plan.  It allows requesting provider’s offices, or facilities, to electronically enter member clinical information to obtain authorization, track status and view cases.

Access the iExchange provider portal here: iEXCHANGE

If you do not have an iExchange account, please click here to fill out the iExchange Request Form.

For help changing your iExchange password, please click here.

 BH Prior Authorization Forms 

• Extended Session Request Form
• Behavioral Health Out-of-Network Outpatient Service Request Form

Select a Plan Type

Commercial

• APS Prior Authorization Grid (Effective 1/1/2012)
• HMO, PPO, POS, UNM Custom Care & iPlan In-Network Prior Authorization Grid (Effective 1/1/2012)
• iPlan Narrative
• PPO & POS Out-of-Network Prior Authorization Grid (Effective 1/1/2012)
• State of New Mexico Prior Authorization Grid (Effective 1/1/2012)
• PNM Prior Authorization Grid (Effective 1/1/2012)

Medicaid

• Salud Prior Authorization Grid (Effective 1/1/2012)
• State Coverage Insurance (SCI) Prior Authorization Grid (Effective 1/1/2012)

Medicare

• Lovelace Medicare Plan (NM) Prior Authorization Grid (Effective 1/1/2012)
• Lovelace Medicare Plan (OK) Prior Authorization Grid (Effective 1/1/2012)

• Prior Authorization Request Form #1
• Prior Authorization Request Form #2 (Please use for Home Healthcare, Home Infusion Therapy and Durable Medical Equipment)
• Prior Authorization Request Form 3 OK DME 01-12.pdf for Lovelace Medicar Plan in Oklahoma
• Click here to access the Prior Auth for Pharmacy Services Form

Questions about prior authorizations?

We’re here to help!
You can reach us at 505.727.LOVE or toll free at 800.808.7363.
You can send a fax at 505.727.5303

Click here for more information on our Health Plan Medical Directors.

Images: 

File: 

APS_4.1.11.xlsx

CHMO_PPO-POSinNet_UNM_iPlaninNet_4.1.11.xlsx

iPlan OON_Effective_4.1.11.xlsx

LSP_Effective_4.1.11.xlsx

PPO_POS_OON_4.1.11.xlsx

Salud_Effective_4.1.11.xlsx

SCI_Effective_4.1.11.xlsx

SONM_4.1.11.xlsx

Form_PA Request Form 1 01-12.pdf

Form_PA Request Form 2 DME 01-12.pdf

Manual Extended Session Request Form 11-15-11.doc

Electronic Extended Session Request Form 11-15-11.doc

Manual BH Out-of-Network Outpatient Service Request Form 11-15-11.doc

Electronic BH Out-of-Network Outpatient Service Request Form 11-15-11.doc

NetOps Reps iExchange form for Providers_Website.doc

Changing Your Password in iExchange.pdf

APS_PA_Grid.xls

Salud_PA_Grid.xls

SCI_PA_Grid.xls

LMP_PA_Grid.xls

OK_Medicare_PA_Grid.xls

SONM_PA_Grid.xls

PNM_PA_Grid.xls

PPO-POS_OutOfNetwork_PA_Grid.xls

iPlan_Narrative.xls

HMO-PPO-POS-UNM-iPLAN_In-network_PA_GRID.xls

Form_Manual Extended Session Request Form 11-15-11.pdf

Form_Manual BH Out-of-Network Outpatient Service Request Form 11-15-11.pdf

Form_Extended session request form electronic- Final 9-21-11.pdf

2BH OON Outpatient Service Request Reformatted 1-11-2012.pdf

Form_PA Request Form 3 OK DME 01-12.pdf