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Verify Procedure Code Preauthorization Requirements and Submit the Request via Availity®

September 11, 2020

Providers can electronically verify Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code-specific preauthorization requirements and submit preauthorization requests handled by Blue Cross and Blue Shield of New Mexico (BCBSNM) all within the Availity Provider Portal.

Checking patient eligibility and benefits is an imperative first step to confirm coverage and preauthorization requirements prior to rendering services. The Availity Eligibility and Benefits Inquiry allows you to quickly obtain preauthorization requirements by procedure code, along with contact information for the preauthorization entity. If BCBSNM requires preauthorization for the service or CPT/HCPCS code(s), you can easily submit the request online using the Availity Authorizations tool. As a reminder, the procedure code inquiry option is for preauthorization determination only and is not a code-specific quote of benefits.

Step 1 – Determine code-specific preauthorization requirements via the Availity:

  • Complete the eligibility and benefit inquiry entry (ANSI 270) by selecting a benefit/service type and/or enter a valid CPT/HCPCS code(s) and the associated place of service. Providers may enter up to eight CPT/HCPCS codes in the inquiry.
  • The eligibility and benefit inquiry response (ANSI 271) displays specific preauthorization requirements in the Pre-Authorization Info tab for the benefit/service type and/or CPT/HCPCS codes entered in the inquiry.

Note: If a benefit/service type is not selected, the place of service and at least one CPT/HCPCS code is required. If a CPT/HCPCS code is not entered, the place of service and benefit/service type is required.

Exceptions

CPT/HCPCS code inquiry for preauthorization is not yet supported for the following lines of business:

  • Federal Employee Program® (FEP®)
  • Blue Cross Medicare Advantage (HMO)SM and Blue Cross Medicare Advantage (PPO)SM

Step 2 – Submit required preauthorization requests handled by BCBSNM via Availity:

  • Select the Patient Registration menu option, choose Authorizations & Referrals, then Authorizations
  • Select Payer BCBSNM, then select your organization
  • Select Inpatient Authorization or Outpatient Authorization
  • Enter preauthorization request
  • Review and submit

Important Reminders

The process of submitting benefit preauthorization requests through eviCore healthcare (eviCore) or other vendors has not changed.

For More Information

Refer to the educational Availity Eligibility and Benefits user guide and Availity Authorizations user guide located under the Provider Tools section of our website. Additionally, you can visit our Provider Training page to register for upcoming online training sessions.

Have additional questions or need customized training? Email our Provider Education Consultants for assistance.

Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized 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 or contract of coverage applicable on the date services were rendered. If you have any questions, please call the number on the member's ID card.

CPT copyright 2020 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

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. BCBSNM makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.