BCBSNM Preauthorization Changes Beginning Jan. 1, 2019

November 21, 2018

Effective Jan. 1, 2019, Blue Cross and Blue Shield of New Mexico (BCBSNM) will be updating preauthorization requirements for 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 and Wellbeing Management option. These updated requirements are expected to include the application of preauthorization to more services. This may reduce post-service denials for lack of medical necessity.

Patient eligibility and benefits should be verified prior to every scheduled appointment. Eligibility and benefit information includes membership verification, coverage status and, preauthorization requirements. To obtain fast, efficient, detailed information for BCBSNM members, please access the Availity® Eligibility and Benefits tool located at . Please note that you must be registered with Availity to gain access to this free online tool. Additional tip sheets are available on the BCBSNM Provider website under Claims and Eligibility. Watch for future updates to the preauthorization requirements list reflecting the 2019 changes on the preauthorizations page at

For additional information, please contact your Provider Network Representative.

Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM. Availity is solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.

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