CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Procedures Requiring Prior Authorization (Code List)

Lists CPT/HCPCS codes and service categories for which prior authorization may be required for certain BCBSNM commercial non-HMO members and describes related program requirements and provider guidance.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyProcedures Requiring Prior Authorization (Code List)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionProviders must check member eligibility and benefits prior to rendering services and obtain required prior authorization through BCBSNM or designated utilization management vendors.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleprocedure codes included on list

09/18/23most recent update date

01/01/23effective date

Coverage Criteria & Operational Rules

Coverage criteria and operational rules

Prior authorization may be required for listed services for some commercial non-HMO members; presence on the list does not guarantee coverage. Providers must confirm member eligibility and obtain any required prior authorization through BCBSNM or a designated utilization management vendor.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyProcedures Requiring Prior Authorization (Code List)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionProviders must check member eligibility and benefits prior to rendering services and obtain required prior authorization through BCBSNM or designated utilization management vendors.

SourceLink

On This Page

ALL of the following

Providers must check eligibility and benefits for each patient prior to rendering services to confirm benefits, prior authorization requirements, and which utilization management vendor must be used, if applicable.
Prior authorization for services on this list must be obtained through Blue Cross and Blue Shield of New Mexico (BCBSNM) or the designated utilization management vendor; services performed without required prior authorization will be denied for payment.
Obtaining prior authorization is not a substitute for checking eligibility and benefits.

ALL of the following

Presence of a code on this list does not necessarily indicate coverage under the member's benefits contract; consult the member benefit booklet or contact customer service to determine coverage for a specific service.

Codes, Program Rules, and Service Definitions

Selected CPT codes requiring prior authorization for behavioral/mental health services and testingCPTCovered

97151	Bhv Id Assmt By Phys/Qhp
97152	Bhv Id Suprt Assmt By 1 Tech
97153	Adaptive Behavior Tx By Tech
97154	Grp Adapt Bhv Tx By Tech
90870	Electroconvulsive Therapy (Includes Necessary Monitoring)
90867	rTMS Treatment Plan
90868	rTMS Subsequent Delivery And Management, Per Session
90869	rTMS Motor Threshold Re-Determination
96130	Psychological Interpretation And Reporting Following Testing, First Hour
96136	Administration Of Psychological/Neuropsychological Testing By Physician Or Psychologist, First 30 Minutes

rTMS standard course

Standard course length36 sessions: 1 daily session, 5 days/week for up to 6 weeks plus a 3-week taper (3 sessions, then 2, then 1)

Repeat policyTreatment course may be repeated after a 6-month cessation period

Same-day restrictionrTMS cannot be administered on the same day as PHP, IOP, ECT, or ABA care level services

Partial Hospitalization Program (PHP) typical hours

Typical daily hours5 to 8 hours per day

Weekly frequency5 days per week

Minimum weekly hoursNot less than 20 hours of treatment services per week

Provider Requirements & Authorization Process

Note

Eligibility & Portal Guidance

Providers must verify member eligibility and benefits before providing services. Check if prior authorization or utilization management vendor approval is required for the member's plan, since requirements vary by contract and product (for example, some commercial non‑HMO products such as PPO, Blue Choice Preferred PPO, Blue Choice PPO, Blue Options/Blue Choice Options, and Blue HPN may require prior authorization). Eligibility and benefits inquiries can be submitted electronically (270 transactions) via the Availity Provider Portal (availity.com) or another preferred web vendor portal. Verifying eligibility is not replaced by obtaining prior authorization; both steps are required when applicable.

Check the member’s benefit booklet or contact BCBSNM customer service to confirm coverage for a specific service or supply.
Use Availity® Provider Portal (availity.com) or other vendor portals for electronic 270 eligibility/benefits inquiries.
Confirm which utilization management vendor (if any) must be used for prior authorization for the member’s product.

Prior Authorization

Prior Authorization Requirement

Services requiring prior authorization that are performed without the required authorization will be denied for payment, and providers may not seek reimbursement from BCBSNM members. Prior authorization for some services must be obtained directly from Blue Cross and Blue Shield of New Mexico; prior authorization for other services may require use of a utilization management vendor. Availity is a third‑party portal operated by Availity, LLC; BCBSNM provides administrative access but does not endorse third‑party products or services.

Services on the prior authorization list may change throughout the year; presence on the list does not guarantee coverage under the member’s contract.
Providers must confirm both eligibility and whether prior authorization is required prior to rendering services.
If prior authorization is required, follow the specified submission route (BCBSNM or designated utilization management vendor).

Service Definitions

Applied Behavior Analysis (ABA)

DefinitionA method of therapy utilized to improve or change specific behaviors of members who have a diagnosis within the Pervasive and specific developmental disorders category of ICD-10.

ScopeApplied primarily for members with pervasive and specific developmental disorders

Service labelReferred to in policy as Applied Behavior Analysis (ABA)

Intensive Outpatient Program (IOP)

DefinitionA freestanding or hospital-based program that provides services for at least three hours per day, two or more days per week to treat mental illness, substance use disorders, or co-occurring conditions.

Program focusMay offer integrated assessment, treatment and discharge planning for co-occurring mental illness and substance use disorders

Typical intensityAt least 3 hours/day on 2+ days/week

Partial Hospitalization Treatment Program (PHP)

DefinitionA Claim Administrator–approved planned program of a hospital or SUD treatment facility providing structured behavioral healthcare typically 5 to 8 hours per day, 5 days per week; participants are not residents and do not require 24-hour supervision.

Staffing/medical supervisionProgram is medically supervised by a physician and nurse; psychiatrist must see the patient face to face at least once weekly and be available to the program as needed.

Minimum weekly hoursNot less than 20 hours of treatment services per week

Repetitive Transcranial Magnetic Stimulation (rTMS)

DefinitionA form of brain stimulation therapy used to treat psychiatric conditions in a facility/clinic setting following a standard course of sessions.

Typical scheduleUsually 1 daily session, 5 times per week for up to 6 weeks, followed by a 3-week taper (total 36 sessions)

Administration settingProvided in facility/clinic settings; subject to same-day care level restrictions (cannot be given same day as PHP, IOP, ECT, or ABA)