2019 Benefit Preauthorization Changes: eviCore Training, Reminders and Resources

December 5, 2018

We know it's a busy time of year, so we wanted to remind you of some upcoming changes, as well as related resources to help you and your staff prepare.

As we announced in November 2018, Blue Cross and Blue Shield of New Mexico (BCBSNM) will expand the number of outpatient services requiring benefit preauthorization for some BCBSNM members with commercial PPO products/networks, effective Jan. 1, 2019. With this expansion, you will need to obtain benefit preauthorization through eviCore healthcare (eviCore) for the following care categories (eviCore is an independent specialty medical benefits management company that provides utilization management for BCBSNM):

  • Advanced Imaging
  • Musculoskeletal (includes joint and spine surgery)
  • Pain Management

We work to make health care more affordable for our members through initiatives and programs focused on providing the access to care that our members need. That's why we will be working more closely with eviCore for preauthorization of certain services and why some other services will now require preauthorization by BCBSNM.

Sign Up for an eviCore Training Session
To help you and your staff get ready for these benefit preauthorization requirement changes, eviCore will be hosting several online orientation sessions. You will be able to attend the web orientation session that works best for you and your schedule. Visit the Provider Resource page  on the eviCore website, where you will find the training session invite, along with registration instructions.

Benefit preauthorization through BCBSNM will continue to be required for other services/care categories. For benefit preauthorization through BCBSNM, we encourage you to use our online tool, iExchange®.

Services performed without benefit preauthorization, if required, will be denied for payment and providers may not seek reimbursement from BCBSNM members.Obtaining benefit preauthorization/pre-notification is not a substitute for confirming eligibility and benefits.

Always Check Eligibility and Benefits First
Benefits will vary based on the service being rendered and individual and group policy elections.?It is critical to check eligibility and benefits for each patient to confirm coverage details. This step will also identify benefit preauthorization/pre-notification requirements and specify utilization management vendors that must be used, if applicable. Submit online eligibility and benefits requests (electronic 270 transactions) via the Availity® Provider Portal  or your preferred web vendor portal.

Learn More About Availity and iExchange
We offer a variety of webinars with an emphasis on using electronic options. We encourage you to attend a BCBSNM Back to Basics: "Availty 101" webinar for an overview of electronic transactions, such as eligibility and benefits, that can be conducted via the Availity Portal. Also, be sure to sign up for an iExchange webinar to learn how to access and navigate our online benefit preauthorization tool. Dates, times and online registration links for upcoming BCBSNM webinars, visit the Webinars page.

Stay Informed
Continue to watch the News and Updates for more information in the coming weeks.

eviCore is an independent specialty medical benefits management company that provides utilization management services for BCBSNM. Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM. iExchange is a trademark of Medecision, Inc. (Medecision), 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 eviCore, Availity or Medecision. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.

Checking eligibility and benefits and/or obtaining preauthorization/pre-notification for a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and their health care provider. If you have any questions, please call the number on the member's BCBSNM ID card.