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Prior Authorization

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What Is Prior Authorization?

Sometimes, you may need to get approval from Blue Cross and Blue Shield of New Mexico before we cover certain health care services and prescription drugs. 

This is called prior authorization, sometimes called prior authorization, preauthorization, pre-certification or prior approval. 

When prior authorization is needed, we, along with outside vendors1, review the requested service or drug to find out if it’s medically necessary and appropriate for your needs. This review does not replace the advice of your provider.

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Do You Need Prior Authorization?

If you're fully insured2, look up procedures, prescription medicines and behavioral health service that might require prior authorization.

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Medical Procedures

Medical procedures like some surgeries, transplants, imaging and other tests often require prior authorization.

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Medical or Prescription Drugs

Search medical drugs, like your prescriptions or specialty prescriptions, that may require prior authorization.

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Behavioral Health Services

Prior authorization may be required for some behavioral services like psychological testing or psychiatric care.

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Review BCBSNM's Prior Authorization Code Lists

To find the full list of services and drugs that require prior authorization, click below to download a copy of the spreadsheet. Except as otherwise noted, these prior authorization requirements are effective as of Jan. 1, 2025:

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Requesting Prior Authorization

We Make Requesting Simple

Most of the time, your doctor will take care of prior authorization before offering care. But, it’s always a good idea to check, especially if your doctor's not in network. If you use an out-of-network doctor, you may need to handle prior authorization. Start by calling the number on your member ID card.  

When you call, we'll need the following information:

  • Your name, subscriber ID number and date of birth
  • Your provider’s name, address and National Provider Identifier (NPI)
  • Information about your medical or behavioral health condition
  • Your provider's proposed treatment plan, including any diagnostic or procedure codes
  • When you'll get care and, if you're being admitted, an estimated length of stay
  • Where you’re being treated

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Not Sure If Your Doctor's In Your Network?

Log in to your member account and use our Provider Finder® tool to search for in-network doctors, hospitals and providers.

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1Carelon Medical Benefits Management (Carelon) is an operating subsidiary of Anthem, Inc., an independent specialty medical benefits management company that provides utilization management services for BCBSNM.

eviCore® is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of Blue Cross and Blue Shield of New Mexico.

2Not sure if you’re fully insured? Check with your HR department or benefits administrator. If you aren’t fully insured, check your benefit booklet to learn your list of services that require prior authorization. If you still have questions, please call the Customer Service number listed on your BCBSNM member ID card.