Preservice Reviews

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 review. 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 because, for example, member eligibility and benefits are reassessed as of the date of service. This is to confirm that circumstances represented in the preservice request must have been 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 is below.

Eligibility and benefits reminder: Check eligibility and benefits first 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 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 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

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, use the  New Mexico Uniform Prior Authorization Form. Refer to Medicaid for prior authorization requirements, code lists and related resources.

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 for providers. 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 01/01/25) and Recommended Clinical Review - Fully Insured (Effective 01/01/25) 

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.

  • 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 Medicaid 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 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:

    • Outpatient Advanced Radiology (see CPT Code list in the section below)

    https://www.bcbsnm.com/provider/claims/claims-and-eligibility/preauthorization

     

    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 Advantage Members

    BCBSNM has contracted with EviCore healthcare to provide utilization management prior authorization services for proton beam therapy for Medicare Advantage members. 

    For other services for our members, prior authorization may be required through BCBSNM.

    Refer to the EviCore Web Portal and select the BCBSNM health plan for the applicable code list for proton beam therapy. 

    Submit your prior authorization request for proton beam therapy to EviCore:

    • Online – The EviCore Web Portal is available 24x7.
    • By phone – Call EviCore toll-free at 855-252-1117, Monday through Friday, 7 a.m. to 7 p.m., except holidays.

    For information about prior authorization requirements for Medicare Advantage members:

    • See the prior authorization lists under Prior Authorization CPT Code Links below 

    Watch News and Updates and Blue Review for additional information on EviCore.

  • Health Advocacy Solutions and Wellbeing Management

    BCBSNM provides 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.

    BCBSNM provides 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. Always check eligibility and benefits through Availity or your preferred web vendor prior to rendering services. This step will help you determine if prior authorization is required. 

    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:

    • Molecular and genomic test 
    • Radiation therapy
    • Advanced imaging
      • Musculoskeletal Pain management
      • Joint surgery
      • Spine surgery
    • Ear, nose and throat
    • Gastroenterology
    • Neurology
    • Outpatient surgery
      • Orthognathic surgery (face reconstruction)
      • Mastopexy (breast lift)
      • Reduction mammaplasty (breast reduction)
    • Sleep studies
    • 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 Availity. The Availity Authorizations tool is accessible to physicians, professional providers and facilities contracted with BCBSNM. 

    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.

  • 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. 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

    Prior Authorization Lists

     

    CPT® copyright 2024 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

  • New Mexico Alternative Arrangements or Gold Carding

    Pursuant to Section 13.10.31.12 NMAC, we provide alternative arrangements with, or gold cards for, participating professional providers who have been determined by us to be frequent submitters of, and in high compliance with, our Prior Authorization and Recommended Clinical Review (together PA) programs (GC Providers) for a certain category of services (“Care Category”) furnished to New Mexico fully insured Members. While active for a GC Provider, this gold card affords the opportunity not to seek PA for the Covered Services within an applicable Care Category when ordered by that GC Provider.

    The Current Procedural Terminology (CPT®) codes for services included within applicable Care Categories are set forth in the NM Alternative Arrangement Care Category List.

  • Non-Covered Service CPT Codes

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.

EviCore healthcare is 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.