Preauthorization



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Also known as prior authorization, pre-notification or pre-certification, preauthorization confirms that a physicians' plan of treatment meets medical necessity criteria under the applicable health benefit plan.


For additional information, refer to the Pre-Service Review for Out-of-Area Members tip sheet, located with other tip sheets under iExchange® on the Provider Tools page. You can also refer to the Electronic Provider Access (EPA) FAQs for additional information. For more information about iExchange, including how to register if you are not a current user or training opportunities, visit the Provider Tools page.


Eligibility and Benefits Reminder: Obtain eligibility and benefits first to confirm membership, verify coverage and determine whether or not preauthorization is required.


For an overview of the preauthorization process and requirements at Blue Cross and Blue Shield of New Mexico (BCBSNM), refer to Section 10  of the Blues Provider Reference Manual .


Medicaid Preauthorization: To obtain preauthorization for services for Medicaid members, please use the form found under Preauthorization Requirements on the Medicaid webpage.


Request, Verify or Obtain Preauthorization

Please do not submit additional documentation unless requested by BCBSNM.

  • Electronic requests – Submit electronic preauthorization requests and inquiries (ANSI 278 transactions) through Availity®  or your preferred electronic health information technology vendor.
  • Online approvalsSign up to use iExchange® – an online tool that supports direct submissions and provides online approval of benefits for inpatient admissions and select outpatient services. Learn more about iExchange
  • Fax request – Complete the Preauthorization Request form
  • Telephone Inquiries – Call the preauthorization number on the back of the member's ID card. Or, call our Health Services department at 800-325-8334 or 505-291-3585.

If you have any questions, please contact the Health Services Department at 800-325-8334.


Preauthorization 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.


Predetermination

A Predetermination is a written request for verification of benefits prior to rendering services.

  • Recommended when the service may be considered experimental, investigational or cosmetic
  • Approvals and denials often are based on approved BCBSNM Medical Policies
  • Not a substitute for the eligibility and benefits verification process

How to Submit a Request for Review

  • Complete the Predetermination Request Form 
  • Use this form to request review of a previously denied predetermination of benefits
  • You will be notified when a final outcome has been reached

Predetermination 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.




For behavioral health services, call 888-898-0070 for authorizations, benefits, and eligibility information. Refer to Section 12, Behavioral Health Services , of the Blues Provider Reference Manual.


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


Refer to the Blue Cross Medicare AdvantageSM section of the Blues Provider Reference Manual for information about preauthorization requirements for Medicare members.


Blue Cross and Blue Shield of New Mexico (BCBSNM) has contracted with eviCore healthcare (eviCore)* to provide certain utilization management preauthorization services. Services requiring preauthorization through eviCore are outlined below. eviCore is an independent company that provides specialty medical benefits management for BCBSNM.


Preauthorization Requirements


BCBSNM requires preauthorization (for medical necessity)** through eviCore for outpatient molecular and genomic testing and outpatient radiation therapy for the following benefit plans:

  • All retail plans
  • All fully insured small and large commercial groups

Refer to the eviCore implementation site Learn more about third-party links and select the BCBSNM health plan for the applicable CPT/HCPCS code list and radiation therapy physician worksheets.


Requires preauthorization (for medical necessity) ** through eviCore for the following codes:

  • Outpatient Molecular Genetics
    To access the BCBSNM eviCore Outpatient Molecular and Genomic, Lab Prior Authorization List and Lab Management Clinical Guidelines, please refer to Lab Resources Learn more about third-party links.
  • Outpatient Radiation Therapy
    For more specific information that applies to Blue Advantage HMO, Blue Advantage Plus HMO, Blue Choice PPO, Blue Premier and Blue Premier Access members refer to the eviCore implementation site Learn more about third-party links and select the BCBSNM health plan for the applicable CPT/HCPCS code list and radiation therapy physician worksheets.

Preauthorization Requirements for:

  • 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

Requires preauthorization (for medical necessity) ** through eviCore for the following codes:

  • Outpatient Molecular Genetics
  • Outpatient Radiation Therapy
  • Musculoskeletal
    • Chiropractic
    • Physical and Occupational Therapy
    • Speech Therapy
    • Spine Surgery (Outpatient/Inpatient)
    • Spine Lumbar Fusion (Outpatient/Inpatient)
    • Interventional Pain
  • Outpatient Cardiology & Radiology
    • Abdomen Imaging
    • Cardiac Imaging
    • Chest Imaging
    • Head Imaging
    • Musculoskeletal
    • Neck Imaging
    • Obstetrical Ultrasound Imaging
    • Oncology Imaging
    • Pelvis Imaging
    • Peripheral Nerve Disorders (Pnd) Imaging
    • Peripheral Vascular Disease (Pvd) Imaging
    • Spine Imaging
  • Outpatient Medical Oncology
  • Outpatient Sleep
  • Outpatient Specialty Drug

For a detailed list of CPT codes that apply to the above services for Blue Medicare Advantage PPO and Blue Medicare Advantage HMO effective 6/1/17, go to Specialty UM Pre-Authorization Program Code Listing PDF Document or access the listing on the BCBSNM Medicare eviCore implementation site Learn more about third-party links and select the Medicare CPT codes list based on the type of service being rendered.


Contact Information


Preauthorization's for the above services through eviCore can be obtained using one of the following methods:

  • The eviCore Healthcare Web Portal Learn more about third-party links 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.

Beginning Jan. 1, 2018, Blue Cross and Blue Shield of New Mexico (BCBSNM) will provide health advocacy solutions as three service options 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.


As part of health advocacy solutions there are new care categories that will require preauthorization. As a reminder, it is always important to check eligibility through AvailityTM or your preferred web vendor prior to rendering services; this step will help you determine if preauthorization is required. For additional information, such as definitions and links to helpful resources, refer to the Eligibility and Benefits section of our Provider website at BCBSNM.com/provider.


In addition to those care categories that already require preauthorization, for members who have one of the three health advocacy solutions service options, as identified by their member ID card, eligibility and benefits should be reviewed for the following care categories to determine if authorization is required through BCBSNM or eviCore:


  • Primary
    • Molecular and Genomic Testing (eviCore)
    • Radiation Therapy (eviCore)
    • Advanced Radiology Imaging (eviCore) – Prenotification Only
  • Advanced
    • Molecular and Genomic Testing (eviCore)
    • Radiation Therapy (eviCore)
    • Sleep Studies and Sleep DME (eviCore)
    • Advanced Radiology Imaging (eviCore)
  • Premier
    • Molecular and Genomic Testing (eviCore)
    • Radiation Therapy (eviCore)
    • Sleep Studies and Sleep DME (eviCore)
    • Advanced Radiology Imaging (eviCore)
    • Cardiology (BCBSNM)
    • Dialysis (BCBSNM) – Prenotification Only
    • Ear Nose and Throat (BCBSNM)
    • Gastroenterology (BCBSNM)
    • Maternity/Delivery (BCBSNM) – Prenotification Only
    • Musculoskeletal (BCBSNM)
    • Neurology (BCBSNM)
    • Outpatient Surgery (BCBSNM)
      • Orthognathic Surgery (BCBSNM)
      • Mastopexy (BCBSNM)
      • Reduction Mammaplasty (BCBSNM)
      • Bunionectomy (BCBSNM)
      • Cardiac Catherization (BCBSNM)
      • Inguinal Hernia Repair (BCBSNM)
      • Lithotripsy (BCBSNM)
    • Specialty Pharmacy (BCBSNM)
    • Wound Care (BCBSNM)
  • To obtain preauthorization through BCBSNM for the services noted above, you will continue to use iExchange®. This online tool is accessible to physicians, professional providers and facilities contracted with BCBSNM. For more information or to set up a new account, refer to the iExchange page in the Provider Tools section of our Provider website.


    Preauthorization for care categories authorized through eviCore can be obtained by accessing the www.evicore.com   or calling 855-252-1117.


    Services performed without preauthorization 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 rereview and/or appeal rights.


    You may also contact your Network Management Consultant for more information.


    Sample Member ID cards with health advocacy solutions:


    Sample 1 


    Sample 2 



    iExchange is a trademark of Medecision, Inc., a separate company that provides collaborative health care management solutions for payers and providers. BCBSNM makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity and Medecision. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.


    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


    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.


    2018 List of CPT Codes requiring Preauthorization for fully insured Members 


    2018 List of CPT Codes requiring Preauthorization for Medicare Members 


    Please visit the Medicaid section of the BCBSNM provider portal for a list of CPT Codes requiring Preauthorization for Medicaid Members.


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

    * 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.

    ** Preauthorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Preauthorization 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.

    Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.