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2018 Blue Cross Community CentennialSM Preauthorization Updates

December 1, 2017

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 for Blue Cross Community Centennial members as noted below.

Services performed without benefit 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. When services may not be covered, members should be notified that they may be billed directly in accordance with NMAC 8.302.2.11(G).

To obtain benefit 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

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.

 

Preauthorization Requirements through eviCore – Effective 01/01/2018

  1. Molecular Genetics
  2. Radiation Therapy

Utilizing the eviCore Healthcare web portal is the most efficient way to initiate a case, check status, review guidelines, view authorizations/eligibility
and more: Visit

https://www.evicore.com/healthplan/bcbs Learn more about third-party links
OR
Call toll-free at 855-252-1117 between 8 a.m. to 8 p.m. (local time) Monday through Friday. Closed holidays.

 

Preauthorization Requirements through BCBSNM – Effective 01/01/2018

Covered Service

Prior Authorization

Allergy care, including tests and serum

Please refer to the procedure code list for authorization requirements

Bariatric surgery

Yes

Breast pumps and replacement supplies

No – subject to benefit and DME dollar amount

Chemotherapy and radiation therapy

Yes – please refer to the procedure code list for
authorization requirements

Covered services provided in school-based health clinics

No

Durable Medical Equipment (DME) – Medical supplies (any single DME greater than $1,500)

Please refer to the procedure code list for authorization requirements and accumulated annual limits without authorization

Emergency dental care

Yes

Diabetes self-management services

Please refer to the procedure code list for authorization requirements

Dialysis services

Requires notification (effective 8/1/17)

Ground and air ambulance

Ground – No

Air – Yes

Hearing services and devices

Yes

Home birthing

Notification is required

Home health care and intravenous services

Yes – please refer to the procedure code list for
authorization requirements

Hospice

Yes

Hospital services (inpatient, outpatient, and skilled nursing)

Please refer to the procedure code list for authorization requirements. Skilled nursing facilities in IL are reviewed through eviCore. Inpatient stays with services that are managed by eviCore will be reviewed through eviCore.

Injections

Please refer to the procedure code list for authorization requirements

Laboratory, X-ray, EKGs, medical imaging services, and other diagnostic tests

Please refer to the procedure code list for authorization requirements

Long-term support services

Long-term support services require pre-assessment, eligibility determination and service planning. This process is completed with the member's care/service coordinator and the treatment team. Once service planning is complete, the authorization process is completed according to State guidelines and requirements. Eligibility is limited to members qualified due to waiver status or eligibility established after evaluation.

Nursing facilities

Yes

Nutritional counseling services

Please refer to the procedure code list for authorization requirements

Minor surgeries

Please refer to the procedure code list for authorization requirements

Office visits to PCPs or specialists, including dieticians, nurse practitioners, and physician assistants

No

Orthotics and prostheses

Please refer to the procedure code list for authorization requirements

Personal care services and private duty nursing (home- or school-based) for children under age 21, who qualify under the EPSDT program

Yes – If a member’s child is disabled, he or she may qualify for more services. Instruct member to call Member Services and ask to speak with a Care Coordinator/Case Manager for more information.

PET, MRA, MRI, and CT scans

Please refer to the procedure code list for authorization requirements

Podiatry (foot and ankle) services

Yes

Pregnancy-related and maternity services

No

Routine physicals, children’s preventive health programs, and Tot-to-Teen checkups

No

Second opinions (in network)

No

Surgery, including pre-and post-operative care: assistant surgeon, anesthesiologist, organ transplants

Please refer to the procedure code list for authorization requirements; all transplants and pre-transplant evaluation require prior authorization

Special rehabilitation services, such as: physical therapy, occupational therapy, speech therapy, cardiac rehabilitation, pulmonary rehabilitation

Please refer to the procedure code list for authorization requirements

 

Summary of Behavioral Health Services

Covered Service

Prior Authorization

Inpatient Psychiatric Services

Yes

Inpatient Substance Abuse Services

Yes

Mental Health Residential  (up to age 21)

Yes

Sub Acute Residential

Yes
Only covered service for Centennial Care

Substance Abuse Residential (up to age 21)

Yes
Only covered service for Centennial Care

Community Mental Health Services

Please refer to the procedure code list for authorization requirements

Medication-Assisted Treatment for Opioid Dependence

No
Only covered service for Centennial Care

Applied Behavioral Analysis (ABA) (up to age 21)

Yes, Stage 3
Only covered service for Centennial Care

Professional Outpatient Services

Please refer to the procedure code list for authorization requirements

Electroconvulsive Therapy

Yes

Developmental Testing

Please refer to the procedure code list for authorization requirements

Early, Periodic Screen, Diagnostic and Treatment Services

No

Group Home

Yes
Only covered service for Centennial Care

Respite Care (up to age 21)

No
Only covered service for Centennial Care

Telehealth Services

No

Value-Added Service – Infant Mental Health

Yes
Only a covered service for Centennial Care

Value-Added Service – Transitional Living

Yes
Only a covered service for Centennial Care

Please view the comprehensive preauthorization grid for a list of procedure codes that require review.
The PDF document allows for bookmarking and searching for the code.