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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.

 




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.


Effective February 20, 2017, Blue Cross and Blue Shield of New Mexico (BCBSNM) has contracted with eviCore healthcare (eviCore) to provide certain utilization management services for outpatient molecular and genomic testing and outpatient radiation therapy for our Blue Cross Community CentennialSM plan. eviCore is an independent company that provides specialty medical benefits management for BCBSNM.


Preauthorization Requirements
BCBSNM requires preauthorization (for medical necessity)* through eviCore for outpatient molecular and genomic testing and outpatient radiation therapy for the following benefit plans:

  • Blue Cross Community Centennial
  • All retail plans
  • All fully insured small and large commercial groups

Refer to the eviCore implementation site and select the BCBSNM health plan for the applicable CPT/HCPCS code list and radiation therapy physician worksheets.


Contact Information
eviCore preauthorization's for outpatient molecular and genomic testing and outpatient radiation therapy can be obtained using one of the following methods:

  • The eviCore Healthcare Web Portal is available 24x7. After a one-time registration, you are able to initiate a case, check status, review guidelines, view authorizations/eligibility and more. The Web Portal is the quickest, most efficient way to obtain information.
  • Providers can call toll-free at 855-252-1117 between 7 a.m. to 7 p.m. (local time) Monday through Friday.
  • More specific program-related information can be found on the eviCore implementation site .

* 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.


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


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.





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.


Related Information


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


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.


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