Standards and Requirements

Affordable Care Act (ACA)

The new health care law offers a host of coverage changes and opportunities beginning in 2014. Blue Cross and Blue Shield of New Mexico (BCBSNM) is committed to implementing coverage changes to comply with ACA requirements and to better meet the needs and expectations of you and your patients. Learn More.

ANSI 5010

The means by which BCBSNM exchanges member data with providers will change dramatically over the next several years. Upgrading ANSI 4010 to ANSI 5010 is required by a directive from the U.S. Department of Health and Human Services. That directive makes the same requirement of providers. Learn More.

Federal Employee Program® (FEP®)

For further information regarding specific Federal Employee Program (FEP) Medical Policies or Federal Employee Program (FEP) Service Benefit Plan Brochure, please visit the FEP website to learn more.


On Jan. 16, 2009, the U.S. Department of Health and Human Services released a final rule mandating that everyone covered by the Health Insurance Portability and Accountability Act must transition from ICD-9 code sets and adopt ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes. Learn More.

Medical Policies

Medical Policies are based on research that provides evidence of scientific merit for a particular medical technology. In most cases, they are used as guidelines for coverage determinations in health care benefit programs. Explore more about Medical Policies.

Medical Policy and Prior Authorization for Out-of-Area Members

Medical Policy and Prior Authorization for Out-of-Area Members

Medical Records Documentation Standards

Medical Records Documentation Standards

Provider Reference Manual

The Provider Reference Manual is designed for ease of use while providing a comprehensive resource tool for your office View the Provider Reference Manual

Reimbursement Calculations

Learn more about the the RBRVS relative values units to calculate your reimbursement.

Clinical Payment and Coding Policies

Clinical payment and coding policies are based on criteria developed by specialized professional societies, national guidelines (e.g. Milliman Care Guidelines (MCG)) and the CMS Provider Reimbursement Manual.

Documentation Guidelines for Urine Drug Testing

BCBSNM processes and reimburses claims for urine drug testing in accordance with BCBSNM Medical Policy MED207.154, “Drug Testing in Pain Management and Substance Use Disorder Monitoring.” BCBSNM only reimburses claims for urine drug testing that are medically necessary under that medical policy. BCBSNM requires that urine drug testing claims be properly documented and that the documentation reflect the medical necessity of the testing. Learn More.

Providing Reimbursable Telemedicine Services

Blue Cross and Blue Shield of New Mexico (BCBSNM) encourages its contracted providers to furnish covered services to Blue Cross Community Centennial members via qualifying and compliant interactive telecommunications systems and/or asynchronous store-and-forward technology, where clinically appropriate, especially to those members living in rural or frontier areas of the state (Telemedicine). The State of New Mexico Human Services Department (HSD) allows reimbursement for Telemedicine where program requirements are met. Learn More.