What’s Changing: Blue Cross and Blue Shield of New Mexico (BCBSNM) is changing prior authorization requirements for Medicare 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 Availity® or your preferred vendor, prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.
Changes include:
- Jan. 1, 2023 – Addition of Sleep drug codes to be reviewed by eviCore
- Jan. 1, 2023 – Addition of a Radiation Oncology code to be reviewed by eviCore
- Jan. 1, 2023 – Addition of a Specialty Drug code to be reviewed by eviCore
- Jan. 1, 2023 – Addition of prior authorization codes to be reviewed by BCBSNM
- Jan. 1, 2023 – Removal of prior authorization codes previously reviewed by BCBSNM
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.
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 2020 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.
eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for 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.