Print

2018 Additional Preauthorization Requirements

December 1, 2017

(Updated Feb. 19, 2018)

Update: After receiving feedback from the provider community about the new benefit preauthorization requirements, BCBSNM is removing certain codes from the requirements listed for some care categories listed below, effective Feb. 23, 2018. To access the updated list of codes for the additional care categories requiring benefit preauthorization in 2018, please visit the Preauthorization page of the provider website.

We appreciate your feedback and your continued participation in BCBNM’s networks.

Beginning Jan.1, 2018, providers will be required to obtain preauthorization through Blue Cross and Blue Shield of New Mexico (BCBSNM) or eviCore for certain procedures as noted below. These new preauthorization requirements will apply to the fully insured members with PPO, Blue AdvantageSM HMO, Blue CommunitySM HMO, Blue Preferred PlusSM, and HMO network plans. Additionally, these preauthorizations will also apply to fully insured membership with Blue ChoiceSM PPO and Administrative Services Only (ASO) membership with Blue Choice PPO with the Health Advocacy Solutions (HAS)* option.

*Effective 1/1/2018 the Health Advocacy Solutions (HAS) program will require certain care categories preauthorization; for more information go to the Preauthorization page on bcbsnm.com/provider.

The new preauthorization requirements care categories are listed below:

  • Radiation Therapy(eviCore)
  • Genetic Testing(eviCore)
  • Radiology(eviCore)
  • Sleep Studies(eviCore)
  • Advanced Radiology Imaging(eviCore) – Prenotification Only
  • Maternity/Delivery (BCBSNM) – Prenotification Only
  • Dialysis (BCBSNM) – Prenotification Only
  • Musculoskeletal(BCBSNM)
  • Neurology(BCBSNM)
  • Specialty Pharmacy(BCBSNM)
  • Ear, Nose and Throat(BCBSNM)
  • Outpatient Surgery(BCBSNM)
  • Gastroenterology(BCBSNM)
  • Wound Care(BCBSNM)

Services performed without preauthorization may be denied for payment in whole or in part, and you may not seek reimbursement from members.

Member eligibility and benefits should be checked prior to every scheduled appointment. Eligibility and benefit quotes include membership status, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. It is strongly recommended that providers ask to see the member's ID card for current information and a photo ID to guard against medical identity theft.

To obtain preauthorization through BCBSNM for the care categories noted above, you may continue to use iExchange®. This online tool is accessible to physicians, professional providers and facilities contracted with BCBSNM. For more information or to set up a new account, refer to the iExchange page in the Provider Tools section of our Provider website.

Our goal is to provide our members with access to quality, cost-effective health care. If you have any questions, please contact your Network Management Consultant PDF Document.

Sincerely,

Network Management
Blue Cross and Blue Shield of New Mexico

eviCore Web Orientation Schedule

eviCore will be hosting orientation sessions for the following care categories listed below. During these training sessions, Blue Cross and Blue Shield of New Mexico (BCBSNM) will also provide a brief overview of the new Health Advocacy Solutions (HAS) product and AvailityTM roles.

Anyone wishing to attend one of the sessions must register in advance. Sessions are free of charge and will last approximately one hour.

We hope you find one or more of the following session times convenient.

Web Orientation Sessions


Radiation Therapy

Dec. 5, 2017

Tuesday

11:00 a.m. central

Genomic Lab

Dec. 5, 2017

Tuesday

1:00 p.m. central

Radiology (CT/MR/PET)

Dec. 6, 2017

Wednesday

1:00 p.m. central

Sleep Testing

Dec. 7, 2017

Thursday

10:00 a.m. central

Sleep DME

Dec. 7, 2017

Thursday

1:00 p.m. central

How to Register

Please read the following instructions carefully to register for and participate in a session:

  1. Once you have chosen a date and time, please go to http://evicore.webex.com Learn more about third-party links
  2. Click on the “Training Center” tab at the top of the page.
  3. Find the date and time of the orientation session you wish to attend by clicking the “Upcoming” tab. All of the orientation sessions will be named “Blue Cross and Blue Shield of New Mexico Provider Program Name Orientation Session.”   
  4. Click “Register”.
  5. Enter the registration information.

After you have registered for the conference, you will receive an email containing:

  1. The toll-free phone number and pass code you will need for the audio portion of the conference.
  2. A link to the online portion of the conference.
  3. The conference password.

Please keep the registration e-mail so you will have the link to and dial in for the session in which you will be participating.

If you are unable to participate in a session at any of the times listed, you can find a copy of the presentation on the implementation site at https://www.evicore.com/healthplan/BCBSNM_c.Learn more about third-party links

Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized or predetermined for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card.

iExchange is a trademark of Medecision, Inc., a separate company that provides collaborative health care management solutions for payers and providers. BCBSNM makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity and Medecision. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.

eviCore is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of BCBSNM