Medicare Advantage: Preauthorization Change for Psychological and Neuropsychological Testing

October 22, 2018

Blue Cross and Blue Shield of New Mexico (BCBSNM), has made updates to the preauthorization requirements for psychological and neuropsychological testing procedures to help improve member access and help decrease provider administrative responsibilities. These changes affect BCBSNM Medicare AdvantageSM members and were effective June 1, 2018.

For in-network providers, benefit preauthorization of routine psychological and neuropsychological testing is no longer required. Preauthorization will only be enforced if BCBSNM determines a provider’s pattern of testing varies significantly from their provider peer group. Additionally, periodic auditing will be conducted by BCBSNM to evaluate that testing is consistent with the presenting clinical issue, national and local coverage determinations, medical policy and benefit plan design. If benefit preauthorization is required or testing is not consistent with the presenting clinical condition, national and local coverage determinations, medical policy and benefit plan design, BCBSNM will contact the provider to obtain additional information.

If you have any questions, contact your Provider Network Representative. Thank you for your cooperation as we work to optimize our Care Management program to better serve our providers and members.

Please note that the fact that a service has been preauthorized/pre-certified 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.