2018 Blue Cross Community CentennialSM Prior Authorization Updates

October 29, 2018

Blue Cross and Blue Shield of New Mexico (BCBSNM) has updated the available list of procedure codes requiring prior authorization for Blue Cross Community Centennial members to better align with the current prior authorization requirements.

The following changes have been made to the list of procedure codes requiring prior authorization PDF Document for Blue Cross Community Centennial members:

  • Procedure code 90863, pharmacologic management, has been removed, effective Aug. 24, 2018
  • Certain codes 0359T, 0360T, and 0361T, for Applied Behavioral Analysis procedures, have been removed effective Jan. 1, 2018
  • Procedure code T1026 with certain modifiers has now been included on the published list of procedure codes requiring prior authorization. Procedure code T1026 requires prior authorization only for the following modifiers:
    • T1026 UD, U5
    • T1026 UD, U4
    • T1026 UD, U3
    • T1026 UC, U5
    • T1026 UC, U4
    • T1026 UC, U3
  • Procedure codes on page 130-193 (E1235-V5299) were erroneously missing from previous versions of the list of codes requiring prior authorization. The list has been updated to show these codes to better reflect the list of procedure codes requiring prior authorization.

Services performed without benefit prior authorization 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 benefit prior authorization 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 Provider Network Representative PDF Document.

Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been prior authorized 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.

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