Medicaid

Prior Authorization

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.

  • 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.

  • 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.

  • Carelon Medical Benefits Management Prior Authorization Program

    Blue Cross and Blue Shield of New Mexico (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 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 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)

     

    Use the Carelon ProviderPortal for Pre & Post-Service Reviews

    Use the Carelon ProviderPortal  to request prior authorization 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.

    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.

    Carelon Contact Information

    Via Phone: (800) 859-5299

    Online: through the Carelon ProviderPortal 

     

    * 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 preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.

  • Prior Authorization CPT® Code Links

    Prior Authorization Lists

     

    CPT® copyright 2015 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

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.