Prior Authorization

Some services for health care and certain drugs require approval from Blue Cross and Blue Shield of New Mexico. This approval is called “prior authorization” ("PA"). If BCBSNM does not approve the services or drugs, the costs will not be covered (paid) by BCBSNM. You and your provider can still decide to get them, but you may have to pay for them.

When is Approval Needed?

Approval from BCBSNM is required before:

• You are admitted to a hospital for an inpatient procedure
• You receive any of the services listed as needing approval
• You visit a provider that is not in our provider network
• You get a prescription drug that needs approval

Check the list of services requiring approval.

Check the Drug List for drugs that need approval.

How to Request Approval

To request approval, you or your provider must call BCBSNM Health Services. Call 1-877-232-5518, Monday through Friday, 8 a.m. to 5 p.m. MT. In-network providers know which services need to be approved and they will ask BCBSNM for you. Out-of-network providers may not.

Need to locate a provider? Search the Provider Finder^®.

Prior Authorization Statistics

Check out the PA Data Report. This report provides results from last year for PA requests for Medicaid members. It includes data for medical and behavioral health care.

The report shows:

• How many requests were approved or denied
• How quickly decisions were made
• Average and middle (median) wait times
• Whether a request was urgent
• Approvals made after appeals or deadline extensions