Prior Authorization and Utilization Management

Utilization management is at the heart of how you access the right care, at the right place and at the right time. It includes:

We use evidence-based clinical standards of care to make sure you get the health care you need.

What Is Prior Authorization?

Sometimes you may need to get approval from Blue Cross and Blue Shield of New Mexico (BCBSNM) before we will cover certain inpatient, outpatient and home health care services and prescription drugs. This is called prior authorization, preauthorization or prior approval. These terms all refer to the requirements that you may need to meet before treatment may begin.

Who Requests Prior Authorization?

Usually, in-network health care providers will take care of prior authorization before they perform a service. But, it’s always a good idea to check if your providers have the needed approval.

If your providers aren’t in network, you’ll be responsible for getting the prior authorization. If you don’t, we may not cover the cost and you may be fully responsible for the resulting bills. To check if your provider is in network, check Provider Finder®.

You or your provider can request a renewal of a prior authorization up to 60 days before it expires.

BCBSNM contracts with outside vendors, including Carelon Medical Benefits Management® (Carelon), eviCore® healthcare and Magellan Healthcare for certain prior authorization services.

How You Can Request Prior Authorization

Check with us to see if your provider has requested prior authorization before you get any services. To do so, call the number on your BCBSNM member ID card.

If your health care provider has not requested prior authorization, you can request it. To begin, print this prior authorization request form. Give it to your provider to complete and return to BCBSNM. You can also submit the form yourself. Call us if you need help to complete the process.

What Happens During the Prior Authorization Process?

BCBSNM reviews the requested service or drug to see if it’s medically necessary and appropriate for your needs. This review does not replace the advice of your provider.

We need the following information to complete a prior authorization request:

  • 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
  • The proposed treatment plan, including any diagnostic or procedure codes (your provider can help you with these)
  • The date you’ll receive service and the estimated length of stay (if you are being admitted)
  • The place you will receive the service or drug

Do You Need Prior Authorization?

Use the search below to find out if you require prior authorization or not. Note that this search is only for members who are fully insured*. Your procedure can fall under one of the 3 categories shown below.

Medical procedures such as surgeries, transplants, imaging and other tests.

Medical drugs such as prescriptions that you may be taking.

Behavioral services such as mental health, psychological testing and psychiatric care.

What Is a Recommended Clinical Review (Predetermination)?

  • This is an option for utilization management review before having services.  
  • Some services not requiring prior authorization may be reviewed for medical necessity before a claim is paid. 
  • This review may be used if you are not sure about coverage or whether we may not consider it medically necessary.
  • You will work with your provider to submit a request for recommended clinical review (predetermination). 

To find out if this review is available for a specific service, check the Recommended Clinical Review List (predetermination).  BCBSNM updates this list when services are added or removed.  You can also call BCBSNM customer service at the number on your member ID card.      

Recommended clinical review (predetermination) is not a guarantee of benefits.  Actual availability of benefits is subject to eligibility and the other terms, conditions, limitations, and exclusions under your benefit booklet. 

What Is Post-Service Utilization Management Review?

A post-service utilization management review happens after you receive a service. During this review, we check whether a service or drug was medically necessary and covered under your health plan. We may ask your provider for more information.

We may also conduct a post-service utilization management review if you or your provider does not get a required prior authorization before you receive services.

*Not 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 see your list of services that require prior authorization. If you still have questions, call the customer service number listed on your BCBSNM member ID card.

Carelon 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.


Last Updated: Feb. 28, 2023