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 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
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.