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Preauthorization

Also known as prior authorization, pre-notification or pre-certification, preauthorization confirms that a physicians' plan of treatment meets medical necessity criteria under the applicable health benefit plan.

For additional information, refer to the Pre-Service Review for Out-of-Area Members tip sheet, located with other tip sheets under iEXCHANGE® on the Provider Tools page. You can also refer to the Electronic Provider Access (EPA) FAQs for additional information. For more information about iEXCHANGE, including how to register if you are not a current user or training opportunities, visit the Provider Tools page.

Eligibility and Benefits Reminder: Obtain eligibility and benefits first to confirm membership, verify coverage and determine whether or not preauthorization is required. This also applies to prior authorization for high-tech imaging services.

For an overview of the preauthorization process and requirements at Blue Cross and Blue Shield of New Mexico (BCBSNM), refer to Section 10  of the Blues Provider Reference Manual .

Request, Verify or Obtain Preauthorization

Please do not submit additional documentation unless requested by BCBSNM.

  • Electronic requests – Submit electronic preauthorization requests and inquiries (ANSI 278 transactions) through Availity®  or your preferred electronic health information technology vendor.
  • Online approvalsSign up to use iEXCHANGE® – an online tool that supports direct submissions and provides online approval of benefits for inpatient admissions and select outpatient services. Learn more about iEXCHANGE
  • Fax request – Complete the Preauthorization Request form
  • Telephone Inquiries – Call the preauthorization number on the back of the member's ID card. Or, call our Health Services department at 800-325-8334 or 505-291-3585.

View the most common codes that require medical review for preauthorization  or predetermination 

If you have any questions, please contact the Health Services Department at 800-325-8334.

Preauthorization does not guarantee payment. All payments are subject to determination of the insured person's eligibility, payment of required deductibles, copayments and coinsurance amounts, eligibility of charges as covered expenses, and application of the exclusions and limitations and other provisions of the policy at the time the services are rendered.

Predetermination

A Predetermination is a written request for verification of benefits prior to rendering services.

  • Recommended when the service may be considered experimental, investigational or cosmetic
  • Approvals and denials often are based on approved BCBSNM Medical Policies
  • Not a substitute for the eligibility and benefits verification process

How to Submit a Request for Review

  • Complete the Predetermination Request Form 
  • Use this form to request review of a previously denied predetermination of benefits
  • You will be notified when a final outcome has been reached

Predetermination does not guarantee payment. All payments are subject to determination of the insured person's eligibility, payment of required deductibles, copayments and coinsurance amounts, eligibility of charges as covered expenses, application of the exclusions and limitations, and other provisions of the policy at the time services are rendered.



For behavioral health services, call 888-898-0070 for authorizations, benefits, and eligibility information. Refer to Section 12, Behavioral Health Services , of the Blues Provider Reference Manual.


If you are providing services to out-of-area Blue Cross and Blue Shield (BCBS) members, please note:

  • Some BCBS Plans have radiology management programs, other than AIM.
  • These programs may be tied to member benefits, and therefore it is essential to check benefits prior to service by calling the BlueCard Eligibility Hotline at 800-676-BLUE(2583).
  • View the out-of-area Blue Plan's medical policy or general preauthorization information

Refer to the Health Care Management section of the Blue Cross Community CentennialSM provider manual for information about preauthorization requirements for Medicaid members. Preauthorizations can be obtained by calling the BCBSNM Medicaid program number at 1-877-232-5518.


Refer to the Blue Cross Medicare AdvantageSM section of the Blues Provider Reference Manual for information about preauthorization requirements for Medicare members.