Medicaid

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.

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.

• Medicaid Contacts List

Learn more about EPSDT services.

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^® New Mexico Turquoise Care User Manual
• AuthentiCare^® Interactive Voice Response (IVR) Instructions
• AuthentiCare^® Mobile Application Instructions
• AuthentiCare^® Mobile Application Instructions - PALCO
• Electronic Visit Verification Implementation Frequently Asked Questions 
• Electronic Visit Verification Tablets Frequently Asked Questions

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.

• Jan. 16, 2024 – 11 to 11:30 a.m.
• Jan. 30, 2024 – 11 to 11:30 a.m.
• Feb. 13, 2024 – 11 to 11:30 a.m.
• Feb. 27, 2024 – 11 to 11:30 a.m.
• March 12, 2024 – 11 to 11:30 a.m.
• March 26, 2024 – 11 to 11:30 a.m.

Electronic Visit Verification - EPSDT

• 2019 Electronic Visit Verification EPSDT Training
• Electronic Visit Verification Provider Feedback Meeting FAQ, July 2019
• Electronic Visit Verification Stipend for EPSDT Personal Care Services

Electronic Visit Verification - Home Health

• 2023 Electronic Visit Verification Home Health Services Training
• 2022 Electronic Visit Verification Home Health Services Training
• Electronic Visit Verification Implementation for Home Health Care Services Nov. 16, 2022 Notification
• Electronic Visit Verification Implementation for Home Health Care Services - Jan. 1, 2024 Go-Live Update
• Electronic Visit Verification Implementation for Home Health Care Services - Jan. 1, 2024 Go-Live Reminder
• Electronic Visit Verification Stipend for Home Health Care Services

Electronic Visit Verification - Personal Care Services

• Electronic Visit Verification Implementation April 26, 2016 Notification
• Electronic Visit Verification Implementation June 1, 2016 Notification 
• Electronic Visit Verification Implementation August 24, 2016 Notification
• Electronic Visit Verification Notification Dec. 1, 2017
• Electronic Visit Verification Training Communication and Registration Mar. 2, 2018
• TOC PCS Authorization FAQs, March 2019

Electronic Visit Verification - Respite

• Electronic Visit Verification Implementation for Respite Services Dec. 19, 2022 Notification
  
• Electronic Visit Verification Implementation for Respite Services - Jan. 1, 2024 Go-Live Update
• Electronic Visit Verification Implementation for Respite Services - Jan. 1, 2024 Go-Live Reminder

For information about reporting fraud, waste and abuse, refer to the Claims/Deficit Reduction Act section of the

• Turquoise Care Provider Reference Manual

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)

• 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 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

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. Prior authorizations can be obtained by calling the BCBSNM Medicaid program number at 1-877- 232-5518 or with the NM Uniform Prior Authorization Form.

Note: Medical necessity must be determined before an authorization number will be issued.
Claims received that do not have 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 furnished 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.

The following lists are not exhaustive. The presence of codes on these lists does not 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.

• Behavior Health Level of Care Guidelines
• Summary of Services Requiring Prior Authorization for Medicaid 
• List of CPT codes requiring prior authorization for Medicaid
• NM Uniform Prior Authorization Form 
• Provider Reference Manual 
• Prime Therapeutics pharmacy prior authorization tool CoverMyMeds^®

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.)

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. Use the links below to review BCBSNM and vendor review criteria that may apply.

• New Mexico Administrative Code (NMAC)
• Medicare – National and Local Coverage Determination (NCD)/(LCD)
• Medical Policy 
• MCG care guidelines
• American Society of Addiction Medicine (ASAM)
• Carelon Medical Benefits Management
• Prime Therapeutics

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.

• Behavioral Health Outpatient Provider Incentive Program 
• CAHPS Survey Tip Sheet
• Hand Hygiene Can Prevent UTI – Flyer 
• Reducing Urinary Tract Infections in Nursing Homes - Presentation 
• Screening for Clinical Depression Initiative 
• Value-Added Services

• 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.
• 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

• 2024 Agency-Based Community Benefits Provider Qualifications Newsletter - Personal Care Services
• 2024 Self-Directed Community Benefits Provider Qualifications Newsletter - Personal Care Services

Related Information

• New Mexico Health Care Authority        

Pharmacy — view Medicaid drug lists, forms, prior authorization requirements and specialty pharmacy program information.

The Medicaid training is for all provider types including behavioral health and long term care providers.

• Turquoise Care Provider Training
  • Turquoise Care - Behavioral Health Provider Training
  • Turquoise Care - Long Term Services & Supports Provider Training
  • Turquoise Care - Medicaid Home Visiting Program
  • Turquoise Care - Indian Health Service Providers/Tribal 638 Providers/Urban Indian Health Providers Training
  • Depression Screening and Outpatient Provider Incentive Overview
  • Home and Community Based Service (HCBS) Final Settings Rule Training
  • New Mexico Medicaid Agency-Based Community Benefit Program Recruitment
• Dual Special Needs Population Provider Training 
• Fraud Awareness Training Tutorial
• Medicaid Claims Handling for Medicaid Members
• Legally Responsible Individuals as Caregivers
• Long Term Care Nursing Facility Checklist
• Short Term Stay Nursing Facility Checklist

Agency Based Community Benefit Annual Provider Audits Training

• All MCO PCS Requirements Training 2025

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

MCO Treatment and Supervision Documentation Training

• MCO Treatment and Supervision Documentation Training
• MCO Treatment and Supervision Documentation Training (Audio)
• MCO Treatment and Supervision Documentation Checklist

Suicide Prevention, Awareness and Education Training

• Suicide Prevention, Awareness and Education Training

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