Prior Authorization / Approval

Except in an emergency, the following services must be preauthorized by the attending physician through the BCBSNM/HMONM Health Services department.

Please Note: For some services, prior authorization is required only for certain product lines and a call to the member's customer service number (on back of ID card) may be necessary.

• Nonemergency or nonurgent care from a nonparticipating provider (HMONM and Point-of-Service plans only)
• Nonemergency or elective hospital or other facility admission, including rehabilitation, subacute, and Skilled Nursing Care
• Any service provided by another provider that is requested by a specialist
• Home Health Care services
• Home IV services
• Home dialysis
• Hospice care
• Hospital services for dental-related procedures (only the hospital care, not the dental care, is considered a potential benefit)
• Infertility-related services
• High-dose chemotherapy
• All inpatient surgery, selected outpatient surgeries, including cochlear implants, cholecystecotomy, hysterectomy, and all transplants and pretransplant evaluations
• Call Customer Service to see if a member's coverage requires prior authorization for an outpatient surgery. At this time the following outpatient procedures require prior approval:
  • Any surgery for the diagnosis Ptosis
  • Arthroscopy (knee or shoulder)
  • Blepharoplasty
  • Bunionectomy
  • Carpal Tunnel Repair
  • IDET (Intradiscal Electrothermal Annuloplasty)
  • Outpatient Cholecystectomy (Laparoscopic)
  • Outpatient Hysterectomy
  • Potentially cosmetic surgery (e.g., scar revision, keloids)
  • Sclerotherapy
  • Septoplasty
  • Uvulopalatopharyngoplasty (UPPP)
  • Varicose veins/ligation or stripping
• Health education and counseling programs received from a provider who is not the member's PCP; diabetes self-management and educational programs
• Rehabilitative services (inpatient and outpatient physical, occupational, and speech therapy)
• Chiropractic and acupuncture services
• Cardiac and pulmonary rehabilitation
• Treatment of accidental injuries to sound, natural teeth (excluding initial emergency treatment)
• Treatment of temporomandibular joint disorders or injuries
• Durable medical equipment, medical supplies, orthopedic appliances, and prosthetic devices costing over $500 or items or equipment requiring long-term rental. Some equipment will be rented until purchase price is reached.
• Orthopedic devices, insulin pumps, and surgically implanted prosthetics, regardless of the total cost
• Air ambulance services (unless during a medical emergency)
• PET Scans
• Genetic testing or counseling
• Certain medications as listed in Section 9, "Pharmacy Services," in the Provider Reference Manual. In particular, note that the following drugs require prior authorization: growth hormone, interferon, and intravenous gamma globulin. See Drug Prior Authorization Criteria for more information.
• Inpatient and outpatient mental health, drug abuse, and alcoholism services. (Prior authorization must be obtained from Mesa Mental Health except for members belonging to the following plans: Federal Employee Program (FEP), New Mexico Medical Insurance Pool (NMMIP), and non-HMO Alliance.) Whether you call Mesa Mental Health or BCBSNM, you will be transferred to the appropriate area through our tie line. The Mesa Mental Health phone number is 1-800-583-6372.

Note: HMO New Mexico no longer requires prior approval for MRIs after it became apparent that this procedure meets criteria. We continually evaluate our prior authorization list. Updates are provided in your Provider News Brief or you may email Network Services for updated information.

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