Government Programs

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.

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

• These programs may be tied to member benefits, and therefore it is essential to check benefits prior to service by calling the BlueCard Eligibility Hotline at 800-676-BLUE(2583).
• View the out-of-area Blue Plan's medical policy or general prior authorization information

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 Centennial^SM 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:

• 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 

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

BCBSNM has contracted with eviCore Health^TM (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  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  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 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 and 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  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.}

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

Unless otherwise prohibited by law, prior authorizations are required for certain services before they are rendered. Authorizations are based on benefits as well as medical necessity, which are supported through clinical information supplied by requesting physicians. Prior authorizations can be obtained by calling the BCBSNM Medicaid program number at 1-877- 232-5518 or with the NM Uniform Prior Authorization Form.

Note: Medical necessity must be determined before an authorization number will be issued.
Claims received that do not have a prior authorization number will be denied. Providers may not seek payment from the member when a claim is denied for lack of a prior authorization number.

To be covered by the member’s Blue Cross Community Centennial health plan, all services to be furnished by out-of-network providers must be prior authorized by BCBSNM, in addition to meeting all other conditions of coverage. Prior authorization requirements are subject to change.

The following 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.

• Behavior Health Level of Care Guidelines for Centennial Care
• Centennial Care summary of services requiring prior authorization
• NM Uniform Prior Authorization Form 
• Provider Reference Manual 
• Prime Therapeutics pharmacy prior authorization tool CoverMyMeds^®

Digital Lookup Tool for Prior Authorization Requirements

You can also search for prior authorization requirements for Medicaid members using our digital lookup tool. 

(Note: This digital lookup tool is intended for reference purposes only. Information provided is not exhaustive and is subject to change.)

Clinical Review Criteria

Prior authorization reviews use evidence-based clinical standards of care to help determine whether a benefit may be covered under a member’s health plan. Use the links below to review BCBSNM and vendor review criteria that may apply.

• New Mexico Administrative Code (NMAC) 
• Medicare – National and Local Coverage Determination (NCD)/(LCD)
• HCSC Medical Policy 
• MCG care guidelines 
• American Society of Addiction Medicine (ASAM) 
• Carelon Medical Benefits Management 
• Prime Therapeutics