Oct. 1, 2025
We’re changing prior authorization or recommended clinical review directions that may apply to some commercial members and members with Medicare Advantage and Turquoise Care plans.
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 code changes from the Centers for Medicaid & Medicare Services.
For some services and members, prior authorization may be required through Blue Cross and Blue Shield of New Mexico. Utilization management and related services for Medicare Advantage members will be reviewed by EviCore Healthcare. Carelon Medical Benefits Management will review utilization management and related services for some commercial and Medicaid members.
These changes for commercial members begin Jan. 1, 2026:
Addition of Advanced Imaging codes to be reviewed by Carelon
Addition of Sleep codes to be reviewed by Carelon
Addition of Genetic Testing codes to be reviewed by Carelon
These changes for members of government programs begin Jan. 1, 2026:
Addition of Specialty Drug codes to be reviewed by EviCore
Addition of Molecular Genetic Lab Testing codes to be reviewed by EviCore
Addition of Advanced Imaging codes to be reviewed by Carelon (Turquoise Care)
Note: after annual review there are additional changes coming Jan. 1, 2026, across many categories for Medicare Advantage. See the prior authorization code list for specific changes.
More Information and lists: refer to preservice reviews.
Important Reminder: Always check eligibility and benefits first through the Availity® Essentials provider portal or your preferred vendor portal, prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.
Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s coverage contract or guide. If you have any questions, call the number on the member's ID card.
Services performed without required 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 2024 AMA. All rights reserved. CPT is a registered trademark of the AMA.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM. EviCore healthcare is an independent specialty medical benefits management company that provides utilization management services for 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.
BCBSNM makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.