Preauthorization



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BCBSNM has two types of preservice review to assess benefits and medical necessity: preauthorization and predetermination. Similarities predominate over differences between these two types of preservice review. The primary difference is that preauthorization is required for certain services whereas predetermination is elective for services that do not require preauthorization. Once requested, preauthorization and predetermination 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. Furthermore, neither preauthorization nor predetermination guaranty benefits or payment because, for example, member eligibility and benefits are reassessed as of the date of service and the circumstances represented in the request must have been complete and accurate and remain materially the same as of the date of service.


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.


Preauthorization is required for all inpatient services.

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

Participating Providers are required to request preauthorization on the member’s behalf in accordance with the member’s evidence of coverage; failure to do so may result in denial of the provider’s claim and the member cannot be balance billed. Providers should complete the Preauthorization Request form. Preauthorization may also be requested by calling the preauthorization phone number listed on the back of the member’s ID card.

  • 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  and submit it along with your supporting documentation
  • 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.
  • Third-party preauthorization – preauthorization for certain services may be managed by a third party such as eviCore Health™

If you have any questions, please contact the BCBSNM 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 to assess benefits and medical necessity prior to rendering services.  Unlike preauthorization, which is mandatory for certain services, predetermination is elective for certain services not subject to prior authorization.  Additionally:

  • A predetermination is not a substitution for preauthorization.
  • Always check benefits before submitting a predetermination. A predetermination is not available for all procedures. For example, predetermination may not be available for complete or partial bony impacted teeth.
  • Fill out the entire Predetermination 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 Predetermination Request form.

How to Submit a Request for Review


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.




In addition to inpatient services and all other care categories listed in Section 10  of the Provider Reference Manual, as of Jan. 1, 2019 the following outpatient services require preauthorization for all commercial and retail fully-insured members (services subject to prior authorization for self-funded health plans may vary by plan; check plan terms, Availity, or phone the number on the back of the member’s ID card for details):

  • Molecular and Genomic Test (eviCore)
  • Radiation Therapy (eviCore)
  • Advanced Imaging (eviCore)
  • Musculoskeletal (eviCore)
    • Pain management
    • Joint Surgery
    • Spine Surgery
  • Ear, Nose and Throat (ENT)
  • Gastroenterology
  • Neurology
  • Outpatient Surgery
    • Orthognathic surgery (face reconstruction)
    • Mastopexy (breast lift)
    • Reduction mammaplasty (breast reduction)
  • Sleep Studies (eviCore)
  • Specialty Pharmacy
  • Wound Care

For a detailed list of CPT codes that apply to the above services see the Preauthorization CPT Code Lists below.


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 HealthTM (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 for Commercial, Retail and ASO members


BCBSNM requires preauthorization through eviCore for the services listed below 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.


Services requiring preauthorization through eviCore:

  • 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).

Preauthorization Requirements for Blue Cross Medicare Advantage members

BCBSNM requires preauthorization 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 Learn more about third-party links and select the BCBSNM health plan for the applicable CPT/HCPCS code list and radiation therapy physician worksheets.

Services requiring preauthorization through eviCore:

  • Molecular and Genomic Tests
  • Musculoskeletal
    • Chiropractic
    • Physical and Occupational Therapy
    • Speech Therapy
    • Joint Surgery (Outpatient/Inpatient)
    • Spine Surgery (Outpatient/Inpatient)
    • Interventional Pain
  • Outpatient Advanced Radiology
  • Outpatient Medical Oncology
  • Outpatient Sleep
  • Outpatient Specialty Drug

For a detailed list of CPT codes that apply to the above services see the Preauthorization CPT Code Lists below or access the listing on the BCBSNM Medicare eviCore implementation site Learn more about third-party linksand 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, BCBSNM will provide 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.


Beginning Jan. 1, 2019, BCBSNM will provide 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 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 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 or eviCore:


  • Molecular and Genomic Test (eviCore)
  • Radiation Therapy (eviCore)
  • Advanced Imaging (eviCore)
  • Musculoskeletal (eviCore)
    • Pain management
    • Joint Surgery
    • Spine Surgery
  • Ear, Nose and Throat (ENT)
  • Gastroenterologye
  • Neurology
  • Outpatient Surgery
    • Orthognathic surgery (face reconstruction)
    • Mastopexy (breast lift)
    • Reduction mammaplasty (breast reduction)
  • Sleep Studies (eviCore)
  • Specialty Pharmacy
  • Wound Care
  • Dialysis (Prenotification Only, HAS only)
  • Maternity (Prenotification Only, HAS Only)

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.


2019 List of Additional CPT Codes requiring Preauthorization for fully insured and ASO Members 


2019 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.