Except in an emergency, the services listed below (if covered by the member's plan) must be preauthorized by the attending physician through the BCBSNM Health Services Department. Note: For some services, prior authorization is required only for certain coverage plans in order for the member to receive optimal benefits. A call to the member's customer service number on the back of member's ID card may be necessary.
- Nonemergency or nonurgent care from a nonparticipating provider
- Nonemergency or elective hospital or other facility admission, including rehabilitation, subacute, and skilled nursing care
- High-dose chemotherapy
- Home Health Care services
- Home IV services
- Infusion center services
- Home dialysis
- Hospice care
- Hospital services for dental-related procedures (only the hospital/medically related care, not the dental care, is considered a potential benefit)
- Infertility-related services
- All inpatient surgery and selected outpatient surgeries (see below), including, but not limited to the following:
- Cochlear implants
- Hysterectomy
- Breast reduction
- Orthotripsy
- Bariatric surgery
- Cosmetic procedures and all procedures that may be cosmetic, including, but not limited to, abdominoplasty and other skin reduction procedures
- Oral/maxillofacial and temporomandibular joint (TMJ) surgery procedures, which may be subject to benefit limitations
- All transplants and pretransplant evaluations
Note: Benefits for covered services will be approved only when the transplant is performed at a facility that contracts directly with BCBSNM or through our national transplant network. A case manager can assist with information on the exclusive network of contracted facilities and required approvals. Call the Health Services Department for information on the transplant programs. Benefits will not be approved for transplants received at noncontracted facilities. Transplant benefits normally are limited by the member's specific plan, and exclude "search" services.
Certain outpatient procedures require prior approval, including:
- Blepharoplasty
- Rhinoplasty
- Sclerotherapy
- Uvulopalatopharyngoplasty (UPPP)
- Varicose vein treatment by any means, including, but not limited to, ligation, stripping, sclerotherapy, or laser therapy
- Vertebroplasty, kyphoplasty, and IDET (Intradiscal Electrothermal Annuloplasty)
- Potentially cosmetic surgery (e.g., keloids, scar revision, and orthognathic surgery)
- Cosmetic procedures and all procedures that may be cosmetic, including but not limited to abdominoplasty and other skin reduction procedures
Note: The above list is not all-inclusive, as new surgical procedures may need to be reviewed. Contact the Health Services Department regarding any outpatient procedures not listed above.
- Health education and counseling programs received from a provider who is not the member's PCP
- Inpatient rehabilitative services received at an inpatient rehabilitation facility and/or skilled nursing facility
- Outpatient rehabilitative services, including, physical, occupational, and speech therapy, which may be subject to benefit limitations
- Chiropractic, naprapathy, and acupuncture services (for certain benefit plans)
- Cardiac and pulmonary rehabilitation
- Treatment of dental injuries (most BCBSNM benefit plans limit coverage to the treatment of accidental injuries to sound, natural teeth – excluding initial emergency treatment)
- Treatment of TMJ disorders and injuries
- Durable medical equipment and medical supplies with a purchase price over $500, or items or equipment requiring long-term rental. Benefits for rental will not exceed the purchase price of a new unit.
- Orthotics, orthopedic appliances, devices (including custom fitted knee braces), and prosthetic devices regardless of total cost (call to verify plan-specific information).
- Surgically implanted prosthetics, regardless of total cost
- Home sleep studies
- Epidural injections
- Air ambulance services (unless during a medical emergency)
- CT, CTA scans; MRI, MRA scans; PET scans; and nuclear cardiology studies (coordination through American Imaging Management is required for these outpatient diagnostic, nonemergency imaging services; see Section 6.4 in the Provider Reference Manual for further details)
- Genetic testing or counseling
- Certain medications require prior authorization and/or have dispensing limits.
Note: See Drug List Limitations, Exclusions, and Prior Authorization Criteria (PDF) for a complete list of drugs requiring prior authorization.
- Inpatient, residential, and outpatient behavioral/mental health, substance abuse, and alcoholism services (see page 6-1 and Section 10, Behavioral Health and Substance Abuse Services, for further information)
- Private room when a shared room is available and appropriate for the member's condition
- Requests to out-of-network providers for HMO members (see Section 6.2 of Provider Reference Manual)
Note: Even if prior authorization is granted for treatment of a particular service, that authorization normally applies only to the medical necessity of treatment. All services are subject to benefit limitations and exclusions, including consideration of pre-existing conditions.
We continually evaluate our prior authorization list. Updates are provided in your Blue Review or you may email Network Services for updated information.
