Medicaid

Blue Cross and Blue Shield of New Mexico is a Medicaid Managed Care Organization for Turquoise Care, New Mexico’s Medicaid managed care program. We endeavor to provide seamless services for Medicaid-eligible individuals to meet their health care needs across the full array of Medicaid covered benefits, including those for acute and long-term care, behavioral health care, and home and community-based services. We’re committed to identifying members at highest risk of poor health outcomes, using a person-centered approach, developing personalized care plans, and providing appropriate access to covered services, a fundamental focus of the Turquoise Care program.

Carelon Medical Benefits Management Prior Authorization Program
Blue Cross and Blue Shield of New Mexico has contracted with Carelon Medical Benefits Management to provide certain utilization management prior authorization services for certain Commercial, Retail and ASO members and Medicaid Members. Services requiring prior authorization through Carelon are outlined below. Carelon is an independent company that provides specialty medical benefits management for BCBSNM.

Use the Carelon ProviderPortal for Pre & Post-Service Reviews

Use the Carelon ProviderPortal to request prior authorization and respond to post-service review requests by Carelon. Do not submit medical records to BCBSNM for prior authorization or post-service reviews for the care categories managed by Carelon. Medical records may or may not be needed for pre or post service reviews using the Carelon portal due to the smart clinical algorithms within the portal.

Benefits of the Carelon ProviderPortal for Pre & Post-Service Reviews
- Medical records for pre or post-service reviews are not necessary unless specifically requested by Carelon.
- Carelon's ProviderPortal offers self-service, smart clinical algorithms and in many instances real-time determinations
- Check prior authorization status on the Carelon ProviderPortal
- Increase payment certainty
- Faster pre-service decision turnaround times than post service reviews
Services requiring prior authorization through Carelon:
- Outpatient Advanced Radiology (see CPT Code list in the section below)
Use the Carelon ProviderPortal for Pre & Post-Service Reviews

Use the Carelon ProviderPortal to request prior authorization and respond to post-service review requests by Carelon. Do not submit medical records to BCBSNM for prior authorization or post-service reviews for the care categories managed by Carelon. Medical records may or may not be needed for pre or post service reviews using the Carelon portal due to the smart clinical algorithms within the portal.

Member benefits will vary based on the service being rendered and individual and group policy elections. Always check eligibility and benefits first, through the Availity^® Provider Portal or your preferred web vendor, prior to rendering services. This step will help you confirm coverage and other important details, such as prior authorization requirements and vendors, if applicable. 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.

Carelon Contact Information

Via Phone: (800) 859-5299

Online: through the Carelon ProviderPortal

* Prior authorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Prior authorization of a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.
Claims

Participating providers are requested to submit claims within 90 days of the date of service, using the standard CMS-1500 or UB-04 claim form, or electronically. Services billed beyond 180 days from the date of service are not eligible for reimbursement.

Providers may not seek payment from the member for claims submitted after the 180-day filing deadline.
Contacts
- Medicaid Contacts List
Early and Periodic Screening, Diagnostic and Treatment

Learn more about EPSDT services.
Electronic Visit Verification
Mobility Exchange

View the latest news and updates from Mobility eXchange.

The Mobility Exchange Portal is available 24/7 for important notices, software updates, portal changes, troubleshooting issues and helpful tips for providers.

Providers can call the Mobility Exchange Help Line at 949-527-6356 between 8 a.m to 6 p.m. (PST) Monday through Friday. Providers can also email support at mobexhealthsupport@mobexhealth.com.

Fiserv AuthentiCare

For EVV system related issues, please contact AuthentiCare Client Support Services at Authenticare.Support@fiserv.com or by phone at 1-800-441-4667, option 6.
AuthentiCare Monthly Trainings

Providers can request an AuthentiCare training session from the list of dates and times below. Please choose one session and contact AuthentiCare Support at 1-800-441-4667, Option 6 or authenticare.support@fiserv.com to receive the registration information.
- Thursday, Jan. 18, 2024 – 11 a.m. to 1 p.m.
- Thursday, Feb. 15, 2024 – 11 a.m. to 1 p.m.
- Thursday, March 21, 2024 – 11 a.m. to 1 p.m.
- Thursday, April 18, 2024 – 11 a.m. to 1 p.m.
- Thursday, May 16, 2024 – 11 a.m. to 1 p.m.
- Thursday, June 20, 2024 – 11 a.m. to 1 p.m.
- Thursday, July 28, 2024 – 11 a.m. to 1 p.m.
- Thursday, Aug. 15, 2024 – 11 a.m. to 1 p.m.
- Thursday, Sept. 19, 2024 – 11 a.m. to 1 p.m.
- Thursday, Oct. 17, 2024 – 11 a.m. to 1 p.m.
- Thursday, Nov. 21, 2024 – 11 a.m. to 1 p.m.
- Thursday, Dec. 19, 2024 – 11 a.m. to 1 p.m.
AuthentiCare Open Form - Home Health Providers

AuthentiCare will be hosting an Open Forum for all New Mexico Medicaid Home Health providers at the dates and times below. Providers can use this forum to ask questions or seek guidance on AuthentiCare functionality.
Electronic Visit Verification - EPSDT
Electronic Visit Verification - Home Health
Electronic Visit Verification - Personal Care Services
Electronic Visit Verification - Respite
Fraud, Waste and Abuse
For information about reporting fraud, waste and abuse, refer to the Claims/Deficit Reduction Act section of the
- Turquoise Care Provider Reference Manual
Health Homes - CareLink New Mexico
CareLink New Mexico (CLNM) is a program to coordinate the integration of physical and behavioral health services for Medicaid beneficiaries with diagnoses of Serious Mental Illness (SMI), Severe Emotional Disturbance (SED) and Substance Use Disorder (SUD). The following organizations and facilities are available to create network relationships, which may be established through MOAs (required for primary care, local hospitals and residential treatment facilities) or other less formal processes.
- New Mexico Solutions (Bernalillo County)
- University of New Mexico Hospitals (Bernalillo County)
- Mental Health Resources (Curry County)
- Mental Health Resources (DeBaca County)
- Hidalgo Medical Services (Hidalgo and Grant Counties)
- Guidance Center of Lea County (Lea County)
- Mental Health Resources (Quay County)
- Mental Health Resources (Roosevelt County)
- Kewa Pueblo Health Corporation (Sandoval County)
- Presbyterian Medical Services (Sandoval County)
Join the Network
- Refer to the Registration Requirement in the Turquoise Care section of the Provider Reference Manual.
- To join our network, follow the process for Network Participation.
- View a sample copy of the Medicaid Managed Care Medical Services Entity Agreement.
- View a sample copy of the Medicaid Managed Care Amendment.
Member Benefits
- Member Handbook
- Coordination of Behavioral Health Care Services
- Preventive Care Guidelines for Adults
- Preventive Care Guidelines for Children
- Tobacco Cessation Program and Medication Formulary Information
- Virtual Visits Now available for Turquoise Care members
- Dental benefits for Medicaid members are administered by DentaQuest^®. Learn more
- Transportation services are administered by ModivCare^TM Learn more
- Vision benefits for Medicaid members are administered by Davis Vision^® Learn more
Prior Authorization Requirements
Unless otherwise prohibited by law, prior authorizations are required for certain services before they are rendered. Authorizations are based on benefits as well as medical necessity, which are supported through clinical information supplied by requesting physicians.

Medical necessity must be determined before an authorization number is issued.

Claims received without a prior authorization number will be denied. Providers may not seek payment from the member when a claim is denied for lack of a prior authorization number.

To be covered by the member’s Medicaid health plan, all services to be rendered by out-of-network providers must be prior authorized by BCBSNM, in addition to meeting all other conditions of coverage. Prior authorization requirements are subject to change.

Refer to the Medicaid Provider Reference Manual for more information on prior authorization and other topics.

For an overview of requirements, refer to the Summary of Services Requiring Prior Authorization for Medicaid.

For behavioral health-specific information: Refer to the Behavior Health Level of Care Guidelines.

Current Medicaid Procedural Terminology (CPT^®) code lists are located on the Preservice page under Prior Authorization CPT Code Lists. The lists are not exhaustive. The presence of codes on these lists doesn’t necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply.

Digital Lookup Tool for Prior Authorization Requirements
You can also search for prior authorization requirements for Medicaid members using our digital lookup tool.

(Note: This digital lookup tool is intended for reference purposes only. Information provided is not exhaustive and is subject to change.)

How to submit requests for prior authorization

Clinical Review Criteria

Prior authorization reviews use evidence-based clinical standards of care to help determine whether a benefit may be covered under a member’s health plan. Below are the BCBSNM and vendor review criteria that may apply.
- New Mexico Administrative Code
- Medicare – National and Local Coverage Determination
- Medical Policy
- MCG Care Guidelines
- American Society of Addiction Medicine
- Carelon Medical Benefits Management
- Prime Therapeutics
Quality Improvement Program
Goal
The Quality Improvement Program’s primary goal is to improve members’ health status and improved outcomes through a variety of meaningful quality improvement activities that are implemented across all care settings and aims at improving the quality of care and services delivered to our members – your patients.

Scope
The Quality Improvement/Quality Management (QI/QM) Program encompasses all clinical care and services furnished to our members, inclusive of medical, behavioral and long-term care and services. The scope of the quality improvement process includes the process and outcomes of medical, behavioral and long-term care and services; ancillary services; pharmacy services; dental, transportation and vendor services; member services and experience, patient safety and efficient use of resources. The QI/QM program is comprehensive and includes effective mechanisms of ongoing identification, monitoring, and evaluation, all of which rectifies issues that impact the safety, accessibility, availability, continuity and quality of care and services provided to our members.

CAHPS^®
Blue Cross and Blue Shield of New Mexico is dedicated to partnering with providers to help maximize opportunities that improves patient care and the member’s experience with their health plan and their respective providers. BCBSNM utilizes CAHPS^® (Consumer Assessment of Healthcare Providers and Systems) to gauge member experience.

Credentialing Standards

For consideration to participate in the Medicaid network, all licensed physicians and other licensed healthcare professionals who have an independent relationship must complete the following:
- Signed release granting BCBNM access to records for credentialing purposes
- Copy of current, unrestricted New Mexico or applicable state license
- Evidence of liability insurance
- Evidence of current accreditation status
- Primary source verification of Medicare and Medicaid suspensions or exclusions
- If not accredited, any documentation necessary to establish that Waiver of Accreditation Criteria are met (if applicable)
- Any documentation necessary to establish that credentialing/recredentialing standards are met
Participation in QI/QM

Medicaid requires providers and practitioners to cooperate with all Quality Improvement activities, as well as allow the use of provider and/or practitioner performance data, to ensure the success of the QI/QM Program. If you are interested in learning more about the Medicaid QI/QM Program, please email qualityinquiry@bcbsnm.com.
Quality Toolkit
Resources
- Annual Medicaid Agency Based Community Benefit Provider Attestation Form - CMS Final Rule for HCBS
- Turquoise Care Provider Reference Manual
- Note: To request a printed copy of the Turquoise Care Provider Reference Manual, at no charge, please contact your Provider Network Representative.
- Home Delivered Meal Service Referral Form
- Maternal Health
- Medical Records Documentation Standards
- Notification of Birth form
- Preventive Care Guidelines
- Provider Finder^®
- Provider Network Directory Note: This print directory is a list of doctors, hospitals and other providers in our network. The list is current as of the date it was published. For the most current information, use our online search above. The Provider Finder is updated daily.
- Provider Request for Appeal on Behalf of a Medicaid Member
- Sample ID Card
- Ombudsman Specialist - If you have a Medicaid patient who is having difficulty with care coordination or is unable to receive services believed to be covered under Turquoise Care plan benefits, the Ombudsman Specialist may be able to help. Following New Mexico's Medicaid guidelines, the Ombudsman Specialist works to help resolve member issues.
Personal Care Services
Related Information
- New Mexico Health Care Authority
Rx Drugs

Pharmacy — view Medicaid drug lists, forms, prior authorization requirements and specialty pharmacy program information.
Provider Training
The Medicaid training is for all provider types including behavioral health and long term care providers.
Agency Based Community Benefit Annual Provider Audits Training
- All MCO PCS Requirements Training 2026
Critical Incident Reporting Training

All providers for New Mexico Medicaid are required to report any critical incidents of their patients/clients as outlined by the New Mexico Health Care Authority in the following. Please reference the page linked below and the Helpful Documents at the bottom of that page.
- Annual Training for Critical Incident Reporting
- Critical Incident Reporting
Cultural Competency Training

Annual Cultural Competency Training is required by the New Mexico Health Care Authority for all providers contracted within a New Mexico Medicaid network. Please have your 10-digit NPI number ready when starting the training or attestation below. Do not use any dashes or spaces when entering your NPI, and make sure your NPI is entered correctly before proceeding with the rest of the training or attestation.
- Cultural Competency Training
- Cultural Competency Training Attestation
Food is Medicine
- Food is Medicine Training
MCO Treatment and Supervision Documentation Training
Suicide Prevention, Awareness and Education Training
- Suicide Prevention, Awareness and Education Training
Value-Added Services
In addition to Standard Medicaid Benefits, BCBSNM offers additional Value-Added Services (VAS) to help keep your patients and their families healthy.
- Value-Added Services Flier

Related Resources:

Required Cultural Competency Training Available Online

Medicaid

Carelon Medical Benefits Management Prior Authorization Program

Claims

Contacts

Early and Periodic Screening, Diagnostic and Treatment

Electronic Visit Verification

Fraud, Waste and Abuse

Health Homes - CareLink New Mexico

Join the Network

Member Benefits

Prior Authorization Requirements

How to submit requests for prior authorization

Quality Improvement Program

Quality Toolkit

Resources

Rx Drugs

Provider Training

Value-Added Services