Blue Cross and Blue Shield of New Mexico has two types of preservice review to assess benefits and medical necessity: prior authorization and recommended clinical review. There are more similarities than differences between these two types of preservice reviews. The primary difference is that prior authorization is required for certain services. Submitting a request for recommended clinical review is optional and informs the provider of situations where a service could be denied based upon medical necessity, even though prior authorization isn’t required.
Requests for 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. Neither prior authorization nor recommended clinical review guarantee benefits or payment as member eligibility and benefits are reassessed as of the date of service. Circumstances represented in the preservice request must be complete and accurate and remain materially the same as of the date of service.
For in-depth information on prior authorization and recommended clinical review at BCBSNM, refer to Section 10 of our Provider Reference Manual. An overview of processes and requirements are below.
Eligibility and benefits reminder: Always check eligibility and benefits first through the Availity® Essentials or your preferred web vendor portal to confirm membership, verify coverage and determine if prior authorization is required. This step also identifies third party prior authorization vendors, if applicable.
Prior Authorization
Prior authorization requirements for inpatient services and select outpatient services.
Summary of Medical/Surgical and Behavioral Health Services, and Specialty Pharmacy Drugs Requiring Prior Authorization for Administrative Only (ASO) Members Effective 01/01/2026
Summary of Medical/Surgical and Behavioral Health Services, and Specialty Pharmacy Drugs Requiring Prior Authorization for Administrative Only (ASO) Members Effective 01/01/2025
Summary of Medical/Surgical and Behavioral Health Services, and Specialty Pharmacy Drugs Requiring Prior Authorization for Fully Insured Members Effective 01/01/2026
Summary of Medical/Surgical and Behavioral Health Services, and Specialty Pharmacy Drugs Requiring Prior Authorization for Fully Insured Members Effective 04/01/2024
An overview of the prior authorization process and requirements at BCBSNM, can be found in Section 10 of the BCBSNM Provider Reference Manual. For code lists see the Prior Authorization CPT® Code Lists section below.
Medicaid prior authorization: To obtain prior authorization for services for Medicaid members, use the New Mexico Uniform Prior Authorization Form. Refer to Medicaid for prior authorization requirements and related resources. For code lists see the Prior Authorization CPT® Code Lists section below.
Request, verify or obtain prior authorization
Prior authorization requests may be submitted by members or providers.
Participating providers are required to request prior authorization on the member’s behalf in accordance with the member’s evidence of coverage and as specified on published prior authorization code lists. Failure to do so may result in denial of the provider’s claim, and the member cannot be balance billed.
Providers and members will be notified of the determination and will have the opportunity to appeal an adverse determination.
- Use the BlueApprovRSM integrated process through Availity® Essentials to request prior authorization for behavioral health services. Refer to Availity Authorizations and BlueApprovR for more information.
- Additional electronic requests – Submit electronic prior authorization requests and inquiries (ANSI 278 transactions) through Availity or your preferred vendor. You may submit the New Mexico Uniform Prior Authorization Form electronically through Availity by attaching it during the request process.
- Telephone inquiries – Call the prior authorization number on the member's ID card, or call our Health Services Department at 800-325-8334 or 505-291-3585.
- Fax request – Complete the New Mexico 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 healthcare, Carelon Medical Benefits Management or Optum. See below for more information about the lines of business supported, and services prior authorized, by each third party.
- Contact information for New Mexico Uniform Prior Authorization Form – See page one of the form for coverage review hours and phone numbers.
If you have additional questions, contact our 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.
- Refer to these lists for services for which recommended clinical review is available: Recommended Clinical Review - Administrative Services Only (ASO) (Effective 01/01/26) and Recommended Clinical Review - Fully Insured (Effective 01/01/26)
How to submit a request for recommended clinical review
- Recommended clinical review requests may be submitted by members or providers.
- Electronic request – Submit requests online using Availity Attachments.
- Fax request – Complete the recommended clinical review request form and submit it along with supporting documentation.
- Fill out all fields on the request form.
- Always provide procedure and diagnosis codes.
- If applicable, specify left, right or bilateral.
- Regarding major diagnostic tests, 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 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.