Removal of Prior Authorization Requirements for your Medicare Advantage Patients

July 23, 2019

There are important changes to the prior authorization requirements for your Blue Cross and Blue Shield of New Mexico (BCBSNM) patients enrolled in Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM plans.

Beginning Sept. 1, 2019, prior authorization through eviCore healthcare, an independent specialty medical management company, will no longer be required for:

  • Cardiology services for Medicare Advantage patients
  • Specialty Therapy (Physical, Occupational, Speech, Chiropractic) services for Medicare Advantage patients

It is important to use Availity® or your preferred vendor to check eligibility and benefits, determine if you are in-network for your patient and whether any prior authorization or prenotification is required. Availity allows you to determine if prior authorization is required based on the procedure code. Refer to the Eligibility and Benefits web page at for more information on Availity. Providers can also refer to the


web page for more information regarding prior authorizations.

For other services requiring prior authorization through BCBSNM, use iExchange® to preauthorize those services. Refer to this web page for more information or to set up an iExchange account.

Payment may be denied if you perform procedures without obtaining prior authorization when prior authorization is required. If this happens, you may not bill your patients.

As a reminder, it is important to check eligibility and benefits prior to rendering services. This step will help you determine if benefit preauthorization is required for a particular member. For additional information, such as definitions and links to helpful resources, refer to the Eligibility and Benefits section on BCBSNM’s provider website.

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.

eviCore healthcare is an independent specialty medical benefits management company that provides utilization management services for BCBSNM. eviCore is wholly responsible for its own products and services. BCBSNM makes no endorsement, representations or warranties regarding any products or services provided by eviCore.

iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers

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.

BCBSNM makes no endorsement, representations or warranties regarding any products or services offered by Availity, eviCore, or Medecision. The vendors are 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.