As a participating provider in Blue Cross and Blue Shield of New Mexico (BCBSNM) provider networks, you have certain rights and responsibilities that may affect your practice. Some of these are noted below. We publish this information for providers annually.
Your Credentialing Rights
If you’re applying or reapplying to participate in our networks, you have the right to:
- Review information submitted to support your credentialing application
- Update incorrect and/or conflicting information
- Receive the status of your credentialing or recredentialing application upon request
To learn more about these rights: Visit the Credentialing page on our Provider website.
Case Management Programs
You can help our members maintain or improve their health by encouraging them to participate in relevant case management programs. These may include:
- Condition management programs to support members with specific conditions like asthma or diabetes
- Complex case management services for members facing multiple or complicated medical or behavioral health conditions
- Programs to help members transition home after a hospital stay or navigate the health care system
- Wellness and prevention programs for members of all ages
Members can access applicable services for complex and condition case management by:
- Asking to enroll, or having their caregiver ask to enroll
- Referral from a primary care physician, practitioner, hospital or other discharge planner
- Referral through utilization management programs
To refer members to any case management programs: Call the number on the member’s BCBSNM ID card. Our clinicians will collaborate with you to provide our members with available resources and additional support.
Utilization Management Decisions
It’s BCBSNM’s policy that licensed clinical personnel make all utilization management decisions according to the benefit coverage of a member’s health plan, evidence-based medical policies and medical necessity criteria. Decisions are based on appropriateness of care and service, and existence of coverage.
BCBSNM prohibits decisions based on financial incentives. We do not reward practitioners or clinicians for issuing denials of coverage. Financial incentives for utilization management decision makers don’t encourage decisions that result in underutilization.
To obtain the criteria used for utilization management decisions: Call the number on the member’s BCBSNM ID card. You can also refer to BCBSNM’s medical policies, which are available for review online, and the Utilization, Case, Population Health, and Condition Management section in the BCBSNM Provider Reference Manual.
Learn more about Prior Authorization on our Provider website.
Blue Cross and Blue Shield Federal Employee Program® (FEP®) members: In addition to the details provided above, visit fepblue.org for more information about our FEP members. Call 800-325-8334 for questions regarding FEP prior authorizations. For FEP expedited appeals only, the fax number is 972-766-9776.