Fully Insured

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 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.

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 Carelon; 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 (Effective 11/01/23) list.

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 

  • 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.

  • Prior Authorization  Exemption Program

    Effective January 1, 2024, some BCBSNM contracted providers will be granted Gold Card status for certain outpatient drug services delivered to commercial fully insured and Individual & Family Market (Exchange) plan members.

    Gold Card status will be granted to providers who are the most frequent submitters of prior authorizations and demonstrate a prior authorization approval rate of 90 percent or greater on eligible services during the previous calendar year and sign the Gold Card Alternative Agreement.

    Providers approved with Gold Card status will not need to submit prior authorization requests for approved services as part of their agreement.

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.