• What are the time frames required by the Medical Assistance Division (MAD)?
• Do the forms downloaded from Medicaid UR Downloadable Forms need to have carbon copies?
• What hours can I call Medicaid UR customer service?
• What is the Medicaid UR fax number?
• Can eligibility be verified through Medicaid UR customer service?
• Do I need to notify Medicaid UR if we're under new ownership or if we have a new NPI, Taxonomy and/or Legacy number (Medicaid Provider Number), or mailing address?
• What information should I have ready when I call Medicaid UR customer service regarding status of a prior authorization request?
• What type of documentation is required for a successful review?
• How can I avoid Requests for Information (RFIs)?
• How do I ensure my dental review requests are processed quickly?
• How will I be notified when my request for prior approval has been completed?
What are the time frames required by the Medical Assistance Division (MAD)?
Blue Cross and Blue Shield of New Mexico (BCBSNM), serving as the Medicaid Utilization Review contractor, works within time frames required by the Medical Assistance Division. These time frames are based on the BCBSNM contract with MAD and/or the regulations as stated in the MAD Program Policy Manual.
Do the forms downloaded from Medicaid UR Downloadable Forms need to have carbon copies?
No. Carbon copies of forms are not required. Medicaid UR will make copies for distribution to all agencies that previously received carbon copies.
What hours can I call Medicaid UR customer service?
The customer service representatives are available to answer your calls from 8 a.m. to 5 p.m. Mountain Time, Monday through Friday.
What is the Medicaid UR fax number?
The Medicaid UR fax number is 505-746-7292.
Can eligibility be verified through Medicaid UR customer service?
Medicaid UR does not provide eligibility information. Please Contact ACS at 505-246-2056 or 1-800-705-4452 for eligibility information. Remember, it is the provider's responsibility to verify eligibility.
Yes, we need the most current information in our records to ensure that your requests are processed correctly and that you receive correspondence from us. You can call us at 1-800-392-9019 to verify that we have your current information. If a change is needed, please send us the following items:
• A short letter on your letterhead requesting that we update your name and/or provider number.
• A forwarding address card or a forwarding post office label showing your new address and/or name so we can update our labels to ensure that you receive our correspondence.
You will need to provide:
• Recipient number, name, and date of birth
• Your provider number or NPI, and name
• The date the request was sent to us
• Item(s) or service(s) requested
What type of documentation is required for a successful review?
You will need to provide objective clinical/medical documentation to justify services; a diagnosis alone does not support medical necessity. Each review must stand on its own. You will need to "paint the picture" to clearly illustrate why the client needs the specific services. For example, you will need to describe the client's functional limitations in accordance with activities of daily living and demonstrate why the client requires daily (not intermittent, e.g., occasional or "sometimes") hands-on assistance with activities of daily living.
How can I avoid Requests for Information (RFIs)?
• Make sure that you are using the most current MAD form and that you fill out the form completely.
• Ensure that the client's Medicaid number is entered correctly as well as all procedure/provider codes.
• The forms and documentation must contain all required signatures (H&P, Medical Assessments, Level of Care Orders with corresponding dates).
• It is important to be familiar with the criteria for the services you are requesting so you can submit all mandatory and supporting documentation (ensure that the information submitted is consistent and relevant to that specific request).
• Before submitting the form, review the entire document and double-check mathematical calculations.
• Clarify your request (e.g., is the request a "Re-review," "Reconsideration," "Re-admit," "Closure," or "Transfer").
How do I ensure my dental review requests are processed quickly?
Each day, a large number of dental requests for authorization are received by the NMMUR department. Many of these are returned to the provider for more information as the result of an incomplete ADA form or missing supporting documentation.
The most common reasons a request is returned are:
• No subscriber ID number
• No date of birth
• No Provider ID number
• Missing teeth not charted on the ADA form
• Required documentation (x-rays, period charting, etc.) not submitted
• Non-diagnostic x-rays
Please take the time to look over your ADA form before submitting. Also, please look at x-rays being submitted. If they are blurry, too light or too dark, the reviewer will not be able to read them.
By making a few simple checks before you submit a request, you can ensure the process will go smoothly and you will receive your notification promptly.
How will I be notified when my request for prior approval has been completed?
See the Provider Bulletin – Change of Notification Process for UR Prior Approvals for more information.
