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Utilization Management

Administrative Services Only (ASO) Plans

A nurse speaking with a patient.

What's Included in Utilization Management?

Utilization management helps you access the right care, at the right place and at the right time. With utilization management, we look at the use of medical care to make sure a service is appropriate. We use evidence-based clinical standards of care to ensure you get the health care you need.

Utilization management could include a review before or after you get care.

  • Pre-Service Reviews: Prior Authorization (required) or Recommended Clinical Review (optional)
  • Post-Service Review

Learn more about utilization management and, as an ASO member, find resources that can help.

 

How Does Utilization Management Work?

Reviewers with BCBSNM evaluate each patient case to know if it’s necessary to perform the medical procedures and services a healthcare specialist recommends. These reviewers use evidence-based guidelines in their analysis.

Together, your doctor and BCBSNM will perform reviews that help check how effective of your treatments are before, during and after care. These reviews can include:

1Blue Cross and Blue Shield of New Mexico may partner with outside vendors like Carelon Medical Benefits Management® (Carelon), eviCore® healthcare and Magellan Healthcare for some prior authorization services. Carelon Medical Benefits Management (Carelon) is an independent company that has contracted with BCBSNM to provide utilization management services for members with coverage through BCBSNM.

eviCore healthcare (eviCore) is an independent company that has contracted with BCBSNM to provide prior authorization for expanded outpatient and specialty utilization management for members with coverage through BCBSNM. 

2 Some services not requiring prior authorization may be reviewed for medical necessity before a claim is paid. Recommended clinical review (predetermination) is not a guarantee of benefits. Actual availability of benefits is based on eligibility and the other terms, conditions, limitations, and exclusions under your benefit booklet. 

Not sure if you’re part of an Administrative Services Only (ASO) group plan? ASO (also known as a self-funded or self-insured group plan) is a type of plan where an employer funds its own insurance plan for their employees and pays claims for their employees’ health care. The employer hires an insurance company to handle the administrative tasks (e.g., process claims). Check with your HR department or benefits administrator to ask if you are part of an ASO plan. New Mexico Student Health Plans are also ASO plans. If you still have questions, call the customer service number listed on your BCBSNM member ID card.