Utilization management is at the heart of how you access the right care, at the right place and at the right time. It is a practice that looks at the use of medical care to make sure a service is appropriate. This can include a review before or after you get care.
- Pre-Service Reviews:
Prior Authorization (required for certain services)
Recommended Clinical Review (an optional review) - Post-Service Review
We use evidence-based clinical standards of care to ensure you get the health care you need.
Prior Authorization
What is Prior Authorization?
Some medical treatment requires approval from Blue Cross and Blue Shield of New Mexico before you get care. This is called prior authorization, preauthorization or prior approval. BCBSNM covers certain services for inpatient, outpatient and home health care. We also cover certain prescription drugs.
BCBSNM will confirm what is covered by your plan. We will check to see if the treatment is medically necessary. If you do not get approval for the treatment, the costs will not be covered (paid) by BCBSNM. You and your provider can still decide to get the treatment, but you may have to pay for it.
Do You Need Prior Authorization?
Need to review a full list of services and drugs that require approval? Download one of the lists below.
- Summary of Medical/Surgical and Behavioral Health Services, and Specialty Pharmacy Drugs that Require Prior Authorization for ASO Members
- Outpatient Medical/Surgical Procedures that Require Prior Authorization for ASO Members
- Behavioral Health Procedures that Require Prior Authorization for ASO Members
- Specialty Pharmacy Drugs that Require Prior Authorization for ASO Members
Who Requests Prior Authorization?
If you go to a provider in your health plan network, they usually take care of this before they perform a service. But it’s always a good idea to check if your provider has received approval from BCBSNM.
If your provider is not in health plan network, you will need to get prior authorization from BCBSNM. If you don’t, we may not cover the cost. This means you may have to pay the bills. To find out if your provider is in network, check our find care tool.
You or your provider can ask to renew a prior authorization up to 60 days before it expires.
BCBSNM contracts with outside vendors such as Carelon Medical Benefits Management® (Carelon) for certain prior authorization services.
How You Can Request Prior Authorization
- Call BCBSNM:
Check with us to find out if your provider got approval before you get treatment. To do so, you can call the number on your BCBSNM member ID card. - Use the Request Form:
If your health care provider has not requested approval, you can request it. 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 will review the service or drug. They will check to see if it’s medically necessary and will meet your needs. This review does not replace the advice of your provider.
To complete a request, we will need:
- Your name, subscriber ID number and date of birth
- Your provider’s name, address and National Provider Identifier (NPI)
- Your medical or behavioral health condition
- The proposed treatment plan, along with any diagnostic or procedure codes (your provider can help you with these)
- The date you’ll get service and the estimated length of stay (if you will be admitted)
- Where you will get the service or drug