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Blue Cross and Blue Shield of New Mexico's (BCBSNM's) Medicaid plan is Blue Cross Community CentennialSM. This plan focuses on breaking down the financial, cultural, and linguistic barriers preventing low-income families and individuals from accessing health care. Blue Cross Community Centennial maintains and monitors a network of participating providers including physicians, hospitals, skilled nursing facilities, ancillary providers, and other health care providers through which members obtain covered services.

 



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

Electronic Visit Verification (EVV)

Fraud, Waste and Abuse

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

Health Homes – CareLink New Mexico (CLNM)

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) or Severe Emotional Disturbance (SED). 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 les formal processes.


Join the Network

Member Benefits

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. 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 Blue Cross Community Centennial 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.



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.

AIM Specialty Health® (AIM) Prior Authorization Program

Blue Cross and Blue Shield of New Mexico (BCBSNM) has contracted with AIM to provide certain utilization management preauthorization services for certain Commercial, Retail and ASO members and Blue Cross Community Centennial Members. Services requiring preauthorization through AIM are outlined below. AIM is an independent company that provides specialty medical benefits management for BCBSNM.



Use the AIM ProviderPortal for Pre & Post-Service Reviews

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


Benefits of the AIM ProviderPortal for Pre & Post-Service Reviews

  • Medical records for pre or post-service reviews are not necessary unless specifically requested by AIM.
  • AIM's ProviderPortal offers self-service, smart clinical algorithms and in many instances real-time determinations
  • Check preauthorization status on the AIM ProviderPortal
  • Increase payment certainty
  • Faster pre-service decision turnaround times than post service reviews

Services requiring preauthorization through AIM:

  • Molecular and Genomic Tests
  • Radiation Therapy
  • Advanced Imaging
  • Musculoskeletal
    • Pain Management
    • Joint Surgery
    • Spine Surgery
  • Sleep Studies (for ASO and Fully Insured Members with health advocacy solutions or Wellbeing Management plan options).
  • Select Outpatient Procedures (see CPT Code list in the section below)

Use the AIM ProviderPortal for Pre & Post-Service Reviews

Use the AIM ProviderPortal to request preauthorization and respond to post-service review requests by AIM. Do not submit medical records to BCBSNM for preauthorization or post-service reviews for the care categories managed by AIM.  Medical records may or may not be needed for pre or post service reviews using the AIM 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.


AIM Contact Information

Via Phone: (800) 859-5299

Online: through the AIM ProviderPortal



* Preauthorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Preauthorization 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.

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 Community CentennialSM 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. Blue Cross and Blue Shield of New Mexico (BCBSNM) utilizes CAHPS® (Consumer Assessment of Healthcare Providers and Systems) to gauge member experience. 


Credentialing Standards

For consideration to participate in the Blue Cross Community Centennial 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

Blue Cross Community Centennial 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 Blue Cross Community Centennial QI/QM Program, please email qualityinquiry@bcbsnm.com.

Quality Toolkit

Resources

Related Information

Rx Drugs

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

Provider Training

The Blue Cross Community Centennial training is for all provider types including behavioral health and long term care providers.

Annual Cultural Competency Training is required by the New Mexico Human Services Department for all providers contracted within a New Mexico Medicaid network, like Blue Cross Community Centennial. 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.

Community agencies for Blue Cross Community Centennial (or NM Medicaid) are required to report any critical incidents of their patients/clients as outlined by the NM Human Services Department (HSD) in the following. Please reference the page linked below and the Helpful Documents at the bottom of that page.

Value Added Services

In addition to Standard Medicaid Benefits, Blue Cross Community Centennial offers additional Value-Added Services (VAS) to help keep your patients and their families healthy.


Highlighted Services

Such services are funded in part with the State of New Mexico.

Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association