Preservice Reviews

Blue Cross and Blue Shield of New Mexico (BCBSNM) has two types of preservice review to assess benefits and medical necessity: prior authorization and recommended clinical review. Similarities predominate over differences between these two types of preservice review. The primary difference is that prior authorization is required for certain services whereas the provider has the option of submitting a Recommended Clinical Review request before services are rendered and informs the provider of situations where a service could be denied based upon medical necessity.

Once requested, prior authorization and recommended clinical review are processed in the same manner including, but not limited to, which reviewers are qualified to approve and deny, timelines, and notices, including appeal rights. Furthermore, neither prior authorization nor recommended clinical review guaranty benefits or payment because, for example, member eligibility and benefits are reassessed as of the date of service and the circumstances represented in the request must have been complete and accurate and remain materially the same as of the date of service.

Eligibility and Benefits Reminder: Obtain eligibility and benefits first to confirm membership, verify coverage and determine whether or not prior authorization is required.

Prior Authorization

Prior authorization is required for all inpatient services and select outpatient services.

Summary of Medical/Surgical and Behavioral Health Services, and Specialty Pharmacy Drugs Requiring Prior Authorization for Fully Insured and Administrative Only (ASO) Members Effective 01/01/2023 through 09/17/2023

Summary of Medical/Surgical and Behavioral Health Services, and Specialty Pharmacy Drugs Requiring Prior Authorization for Administrative Only (ASO) Members Effective 09/18/2023

Summary of Medical/Surgical and Behavioral Health Services, and Specialty Pharmacy Drugs Requiring Prior Authorization for Fully Insured Members Effective 09/18/2023

For an overview of the prior authorization process and requirements at BCBSNM, refer to Section 10 of the BCBSNM Provider Reference Manual.

Medicaid Prior authorization: To obtain prior authorization for services for Medicaid members, please use the form found under prior authorization Requirements on the Medicaid webpage.

Request, Verify or Obtain Prior authorization

Participating Providers are required to request prior authorization on the member’s behalf in accordance with the member’s evidence of coverage and listed on the UM Website Prior Authorization List; failure to do so may result in denial of the provider’s claim and the member cannot be balance billed. Providers should complete the Prior authorization Request form. Prior authorization may also be requested by calling the prior authorization phone number listed on the back of the member’s ID card.

Providers and members will be notified of the determination and will have the opportunity to appeal an adverse determination if the Recommended Clinical Review determines the proposed service does not meet medical necessity.

  • BlueApprovRSM – Use BlueApprovR to request prior authorization for some services (visit our BlueApprovR Tools Page for instructions)
  • Additional Electronic requests – Submit electronic prior authorization requests and inquiries (ANSI 278 transactions) through Availity® or your preferred electronic health information technology vendor. Providers may submit the NM Uniform Prior Authorization Form electronically through Availity by attaching it during the request process.
  • Telephone Inquiries – Call the prior authorization number on the back of the member's ID card. Or, call our Health Services department at 800-325-8334 or 505-291-3585.
  • Fax request – Complete the NM Uniform Prior Authorization Form and submit it along with your supporting documentation
  • Third-party prior authorization – prior authorization for certain services may be managed by a third party such as eviCore Health™, Carelon, or Optum; see below for more information about the line(s) of business supported, and services prior authorized, by each third party.
  • Contact Information for NM Uniform Prior Authorization Form

If you have any questions, please contact the BCBSNM Health Services Department at 800-325-8334.

Prior authorization does not guarantee payment. All payments are subject to determination of the insured person's eligibility, payment of required deductibles, copayments and coinsurance amounts, eligibility of charges as covered expenses, and application of the exclusions and limitations and other provisions of the policy at the time the services are rendered.

Recommended Clinical Review

Recommended Clinical Reviews are medical necessity reviews conducted before services are provided. Submitting the request prior to rendering the services is optional and informs the provider and member of situations where a service may not be covered based upon medical necessity.

  • There is no penalty if a provider does not elect to use Recommended Clinical Review, but the service will be subject to post-service review. ​
  • Once a decision has been made on the services reviewed as part of the Recommended Clinical Review request, the same services will not be reviewed for Medical Necessity again on a retrospective basis.​
  • Submitted claims for services not included as part of a request for Recommended Clinical Review, may be reviewed retrospectively.​
  • Providers and members will be notified of the determination and will have the opportunity to appeal an adverse determination if the Recommended Clinical Review determines the proposed service does not meet medical necessity.​
  • You can find a list of services for which Recommended Clinical Review are available on the Recommended Clinical Review - Fully Insured and Administrative Services Only (ASO) (Effective 01/01/23 – 09/17/23), Recommended Clinical Review - Administrative Services Only (ASO) (Effective 09/18/23) and Recommended Clinical Review - Fully Insured (Effective 09/18/23) lists.

How to Submit a Request for Recommended Clinical Review

  • Recommended Clinical Review requests may only be submitted by providers.
  • Electronic request – Submit requests online using Availity's Attachments tool.
  • Fax request – Complete the Recommended Clinical Review Request Form and submit it along with supporting documentation.
  • Fill out the entire Recommended Clinical Review request form.​
  • Always provide procedure code(s) and diagnosis code(s).​
  • If applicable, provide left, right or bilateral.​
  • Regarding major diagnostic tests, please include the patient’s history, physical and any prior testing information.​
  • If indicated, include original photos or digital color copies that clearly show the affected area of the body. This information must be mailed to the address indicated on the Recommended Clinical Review request form.

Recommended Clinical Review does not guarantee payment. All payments are subject to determination of the insured person's eligibility, payment of required deductibles, copayments and coinsurance amounts, eligibility of charges as covered expenses, application of the exclusions and limitations, and other provisions of the policy at the time services are rendered.

  • Behavioral Health

    For behavioral health services, call 888-898-0070 for authorizations, benefits, and eligibility information. Refer to Section 12, Behavioral Health Services, of the BCBSNM Provider Reference Manual.

  • BlueCard (out-of-area)

    If you are providing services to out-of-area Blue Cross and Blue Shield (BCBS) members, please note:

  • Carelon Medical Benefits Management (formerly AIM) Prior Authorization Program

    BCBSNM has contracted with Carelon Medical Benefits Management (Carelon) to provide certain utilization management prior authorization services for certain Commercial, Retail and ASO members and Blue Cross Community CentennialSM Members. Services requiring prior authorization through Carelon are outlined below. Carelon is an independent company that provides specialty medical benefits management for BCBSNM.

    Use the Carelon ProviderPortal for Pre & Post-Service Reviews

    Use the Carelon ProviderPortal  to request prior authorization and/or Recommended Clinical Review (RCR) and  respond to post-service review requests by Carelon. Do not submit medical records to BCBSNM for prior authorization or post-service reviews for the care categories managed by Carelon. Medical records may or may not be needed for pre or post service reviews using the Carelon portal due to the smart clinical algorithms within the portal.

    Benefits of the Carelon ProviderPortal for Pre & Post-Service Reviews

    • Medical records for pre or post-service reviews are not necessary unless specifically requested by Carelon.
    • Carelon's ProviderPortal  offers self-service, smart clinical algorithms and in many instances real-time determinations
    • Check prior authorization status on the Carelon ProviderPortal
    • Increase payment certainty
    • Faster pre-service decision turnaround times than post service reviews

    Services requiring prior authorization through Carelon:

    • Molecular and Genomic Tests
    • Radiation Therapy
    • Advanced Imaging
    • Musculoskeletal
      • Pain Management
      • Joint Surgery
      • Spine Surgery
    • Sleep Studies (for ASO and Fully Insured Members with health advocacy solutions or Wellbeing Management plan options).
    • Select Outpatient Procedures (see CPT Code list in the section below)

    Member benefits will vary based on the service being rendered and individual and group policy elections. Always check eligibility and benefits first, through the Availity® Provider Portal  or your preferred web vendor, prior to rendering services. This step will help you confirm coverage and other important details, such as prior authorization requirements and vendors, if applicable. If prior authorization is required, services performed without prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.

    Use the Carelon ProviderPortal to Submit the New Mexico Uniform Prior Authorization Form
    Providers can use the Carelon ProviderPortal  to submit the New Mexico Uniform Prior Authorization Form for services requiring prior authorization by Carelon. Under "Order Request" simply check the "Submit New Mexico Uniform Prior Authorization Form" box and then click the "Upload Form" box to upload the completed form through the ProviderPortal.

    Carelon Contact Information

    Via Phone: (800) 859-5299

    Online: through the Carelon ProviderPortal 

  • eviCore Prior Authorization Program for Medicare Members

    Refer to the Blue Cross Medicare AdvantageSM section of the BCBSNM Provider Reference Manual for more information about prior authorization requirements for Medicare members.

    BCBSNM has contracted with eviCore HealthTM (eviCore)* to provide certain utilization management prior authorization services for Medicare Members. Services requiring prior authorization through eviCore are outlined below. eviCore is an independent company that provides specialty medical benefits management for BCBSNM.

    Refer to the eviCore implementation site Learn more about third-party links and select the BCBSNM health plan for the applicable CPT/HCPCS code list and radiation therapy physician worksheets.

    Prior authorization Requirements for Blue Cross Medicare Advantage members

    BCBSNM requires prior authorization through eviCore for the services listed below for the following benefit plans:

    • Blue Cross Medicare Advantage (HMO)SM effective 06/01/2017
    • Blue Cross Medicare Advantage (HMO-POS)SM effective 06/01/2017
    • Blue Cross Medicare Advantage (PPO)SM effective 06/01/2017

    Refer to the eviCore implementation site Learn more about third-party links and select the BCBSNM health plan for the applicable CPT/HCPCS code list and radiation therapy physician worksheets.

    Services requiring prior authorization through eviCore:

    • Molecular and Genomic Tests
    • Musculoskeletal
      • Joint Surgery (Outpatient/Inpatient)
      • Spine Surgery (Outpatient/Inpatient)
      • Interventional Pain
    • Outpatient Advanced Radiology
    • Outpatient Medical Oncology
    • Outpatient Sleep
    • Outpatient Specialty Drug

    For a detailed list of CPT codes that apply to the above services see the Prior authorization CPT Code Lists below or access the listing on the BCBSNM Medicare eviCore implementation site Learn more about third-party linksand select the Medicare CPT codes list based on the type of service being rendered.

    Contact Information

    Prior authorization's for the above services through eviCore can be obtained using one of the following methods:

    • The eviCore Healthcare Web Portal Learn more about third-party links is available 24x7. After a one-time registration, you are able to initiate a case, check status, review guidelines, view authorizations/eligibility and more. The Web Portal is the quickest, most efficient way to obtain information.
    • Providers can call toll-free at 855-252-1117 between 7 a.m. to 7 p.m. (local time) Monday through Friday. Review the BCBSNM provider website and Blue Review for additional information on eviCore.

    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 BCBSNM.

    Prior authorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Prior authorization of a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.

  • Health Advocacy Solutions and Wellbeing Management

    Beginning Jan. 1, 2018, BCBSNM will provide health advocacy solutions as a service option available with the Blue ChoiceSM PPO network for select self-funded employer groups. There are dedicated Health Advocates who will deliver personalized communication and educational resources, such as cutting-edge cost transparency tools, to help members make informed decisions concerning their health care.

    Beginning Jan. 1, 2019, BCBSNM will provide Wellbeing Management as a service option available for select self-funded employer groups. Wellbeing Management is a comprehensive health and wellbeing management product to better support members by improving health outcomes and increasing cost savings.

    As part of health advocacy solutions and Wellbeing Management there are new care categories that will require prior authorization. As a reminder, it is always important to check eligibility through AvailityTM or your preferred web vendor prior to rendering services; this step will help you determine if prior authorization is required. For additional information, such as definitions and links to helpful resources, refer to the Eligibility and Benefits section of our provider website.

    In addition to those care categories that already require prior authorization, for members who have the health advocacy solutions or Wellbeing Management service options eligibility and benefits should be reviewed for the following care categories to determine if authorization is required through BCBSNM or eviCore:

    • Molecular and Genomic Test (eviCore)
    • Radiation Therapy (eviCore)
    • Advanced Imaging (eviCore)
    • Musculoskeletal (eviCore)
      • Pain management
      • Joint Surgery
      • Spine Surgery
    • Ear, Nose and Throat (ENT)
    • Gastroenterology
    • Neurology
    • Outpatient Surgery
      • Orthognathic surgery (face reconstruction)
      • Mastopexy (breast lift)
      • Reduction mammaplasty (breast reduction)
    • Sleep Studies (eviCore)
    • Specialty Pharmacy
    • Wound Care
    • Dialysis (Prenotification Only, HAS only)
    • Maternity (Prenotification Only, HAS Only)

    To obtain prior authorization through BCBSNM for the services noted above, continue to use the Availity® Provider Portal. This online tool is accessible to physicians, professional providers and facilities contracted with BCBSNM. Refer to the educational Availity Authorizations User Guide, located in the Provider Tools section of our website for navigational assistance.

    Prior authorization for care categories authorized through eviCore can be obtained by accessing the www.evicore.com   or calling 855-252-1117.

    Services performed without prior authorization may be denied for payment. As a contracted provider, you may not seek reimbursement from members if your claim is denied for failure to preauthorize (or otherwise). For any service not approved for payment, the member and/or provider may have review and/or appeal rights.

    You may also contact your Provider Network Representative for more information.

    Sample Member ID cards with health advocacy solutions:

    Sample 1

    Sample 2

     

    Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to 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 BCBSNM

    BCBSNM makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity or eviCore. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.

  • Optum Prior Authorizations

    Prior authorization for Medicare members assigned to Optum is performed by Optum or eviCore. Providers can identify members assigned to Optum by reviewing the member’s ID Card; Optum Medical Group will be identified as the Member’s PCP.

    The services prior authorized by eviCore are identified in the eviCore section below. All remaining services subject to prior authorization are prior authorized by Optum. Please refer to the Blue Cross Medicare Advantage section of the Provider Reference Manual for more information about Prior Authorization for Medicare members, including a list of services for which Prior Authorization is required. 

    Contact Information

    • Optum Medical Management Phone number: 505-232-1600
    • Toll Free: 855-793-9360
    • Prior Authorization Fax number: 505-232-1386
    • Utilization Management Fax number: 505-232-1387

  • Prior Authorization CPT® Code Links

    These lists are not exhaustive. The presence of codes on these lists does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply.

    Digital Lookup Tool (For Fully Insured Only)


    Review categories below to find out if a member's procedure may require prior authorization.

     

    Prior Authorization Lists

     

    CPT® copyright 2015 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

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 Procedure - Medical procedures such as surgeries, transplants, imaging and other tests.
  • Medical Drugs - Medical drugs such as prescriptions that you may be taking.
  • Behavioral Service - Behavioral services such as mental health, psychological testing and psychiatric care.

Related Resources:

Availity® Essentials is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM. BCBSNM makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity.

Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.