For fully insured members with health plans underwritten by Blue Cross and Blue Shield of New Mexico (BCBSNM), prior authorization requirements for outpatient service categories will be removed effective Sept. 18, 2023. Instead of a required prior authorization, providers will have the option of submitting a Recommended Clinical Review (RCR), formerly Predetermination.
What is Recommended Clinical Review: Recommended Clinical Reviews are optional medical necessity reviews conducted before services are provided. Submitting the request prior to rendering the services is voluntary and informs the provider and member that the service may not be covered based upon medical necessity.
- Services for which Recommended Clinical Review is available may be found at RCR Services List.
- There is no penalty if a provider does not elect to use Recommended Clinical Review, but the claim for service may be subject to post-service medical necessity review.
- Recommended Clinical Reviews for complete requests will be made in seven (7) business days for standard and 24 hours for urgent, failing which the request will be deemed approved.
- Once a decision has been made on the services reviewed as part of the Recommended Clinical Review request, the same services will not be reviewed for medical necessity again on a retrospective basis.
- If the Recommended Clinical Review determines the proposed service does not meet medical necessity, the provider and member will be notified of the adverse determination and will have the same appeal rights and process as they do for denied prior authorizations.
How to submit a Recommended Clinical Review:
- BlueApprovRSM – Use BlueApprovR in Availity Essentials to request Recommended Clinical Reviews at BlueApprovR Tools Page. BlueApprovR is designed to simplify the provider submission process by asking for the minimal necessary information to conduct a medical necessity determination. In many cases, BlueApprovR will approve medical necessity at the point of intake with instantaneous approval. Cases that do not meet auto-approval criteria are sent to appropriate clinicians for determinations.
- Availity® - Submit requests for Recommended Clinical Review through Availity or your preferred electronic health information technology vendor.
- Carelon – Use the Carelon Provider Portal to request Recommended Clinical Reviews for the care categories managed by Carelon (molecular and genomic tests, radiation therapy, advanced imaging, musculoskeletal, sleep studies, select outpatient procedures).
- Telephone – Call the 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 - Complete the Recommended Clinical Review Request Form. Submit it along with supporting documentation.
Refer to the provider tab at www.bcbsnm.com for the list of procedure codes and categories for which a Recommended Clinical Review is available.
Be sure to check eligibility and benefits via Availity® Essentials or your preferred electronic vendor prior to rendering services. This process will also notify you if the service requires prior authorization or is eligible for Recommended Clinical Review for your member.
More Information: refer to the provider tab at www.bcbsnm.com for more information regarding Recommended Clinical Review.
Watch News and Updates for more information.