Prior Authorization Codes Updated, Effective July 1, also watch for Medical Oncology Portal Enhancements 

What’s Changing: Blue Cross and Blue Shield of New Mexico (BCBSNM) is changing prior authorization requirements that may apply for some commercial and Medicaid Blue Cross Community CentennialSM (BCCC) members to reflect new, replaced or removed codes. These changes are based on updates from Utilization Management prior authorization assessment, Current Procedural Terminology (CPT®) code changes released by the American Medical Association or Healthcare Common Procedure Coding System (HCPCS) changes from the Centers for Medicaid & Medicare Services. A summary of changes is included below.

Important Reminder: Always check eligibility and benefits first through the Availity® Provider Portal or your preferred vendor portal, prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.

Changes include:

  • July 1, 2023 – Addition of Medical Oncology drug codes to be reviewed by Carelon Medical Benefits Management (Carelon) formerly AIM Specialty Health (also includes BCCC)
  • July 1, 2023 – Replacement and removal of Musculoskeletal Joint and Spine codes reviewed by Carelon (also includes BCCC)
  • July 1, 2023 – Addition of Genetic Testing codes to be reviewed by Carelon (also includes BCCC)
  • July 1, 2023 – Replacement of an Infusion Site of Care drug code to be reviewed by BCBSNM
  • July 1, 2023 – Addition of Advanced Imaging codes to be reviewed by Carelon (also includes BCCC)

Also, effective May 14, 2023, enhancements to Carelon’s ProviderPortal will create an easier intake process for its Medical Oncology program. Register for a free training from Carelon below:

More Information: Refer to the updated Preauthorization CPT Code Lists section in the Preauthorization area of the website. The code changes will be designated with dates of removal or addition.

Note: Effective April 1, 2023, the prior authorization list will include a link to the medical policy website for review of the specific medical policies associated with the procedure code rather than listing the medical policy number and title for each code. The list will continue to include information on whether prior authorization for the procedure code is managed by BCBSNM or by Carelon.

Avoid post-service medical necessity reviews and delays in claim processing by obtaining prior authorization before rendering services. 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.

CPT copyright 2022 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM.

Carelon Medical Benefits Management (Carelon) is an independent company that has contracted with BCBSNM to provide utilization management services for members with coverage through BCBSNM.

The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.