Addition of New Prior Authorization Requirements for New Mexico Members

November 22, 2019

There are important changes to the prior authorization requirements for some of your Blue Cross and Blue Shield of New Mexico (BCBSNM) commercial patients with PPO, HMO, EPO and POS benefit plans.

Beginning Jan. 1, 2020, the following services will require prior authorization:

  • Outpatient provider-administered drug therapies including Cellular Immunotherapy, Gene Therapy, and other medical benefit drug therapies.

A list of the Drug Therapies Procedure Codes included are posted to the provider website.

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 preauthorization or prenotification is required. Availity allows you to determine if preauthorization is required. Refer to the Eligibility and Benefits web page for more information on Availity. Providers can also refer to the Preauthorization web page for more information regarding preauthorizations.

For services requiring prior authorization through BCBSNM:

  • Coming soon, there will be a new tool available in the Availity Provider Portal called Availity Authorizations, which will be used to submit prior authorizations. Watch the BCBSNM provider website for information on this new tool.
  • At this time, providers, can continue to submit via iExchange®, our web-based automated tool. Refer to this web page for more information or to set up an iExchange account.

Preauthorization through BCBSNM may also be requested by calling the phone number listed on the member/participant's ID card.

As a reminder, it is important to check eligibility and benefits prior to rendering services. This step will help you determine if benefit prior authorization 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.

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, 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.