Prior Authorization Requirements List for Administrative Services Only (ASO) Groups
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This document lists services that require prior authorization or recommended clinical review for Blue Cross Blue Shield of New Mexico Administrative Services Only (ASO) groups and describes notification and preauthorization expectations for providers.
No material clinical or coverage changes in this revision.
Services Requiring Prior Authorization
Prior authorization criteria overview
Services listed require prior authorization for ASO members; benefits and final payment determinations are made when claims are received and depend on member eligibility and certificate of coverage.
Includes acute care, inpatient rehab, cardiac rehab, pain management, skilled nursing, hospice, long term acute/sub-acute care
Pre-stabilization and stabilization care are exceptions and do not require notification
Emergency admissions and post-stabilization care do not require notification but notification is encouraged
Some outpatient reviews are managed through Carelon Medical Benefits Management when applicable
ALL of the following
- Cardiology (select services)
- Gastroenterology (select services)
- Neurology (select services)
- Outpatient surgery (e.g., breast, deactivation of headache triggers, jaw)
- Pain management and wound care services
ALL of the following
- Home health services (including private duty nursing, home infusion)
- Home hospice
- Home hemodialysis
- Non-emergent air ambulance
- Transplant evaluations and transplants
ALL of the following
- Inpatient/residential treatment center (RTC) admissions for mental health and substance use disorder
- Outpatient services such as ABA, ECT, intensive outpatient, partial hospitalization, psychological/neuropsychological testing, repetitive transcranial magnetic stimulation
Pharmacy prior authorization requirements are referenced in separate drug list guides and specialty pharmacy procedure code lists
BCBSNM Health Services phone: 800-325-8334
Code Availability and Listings
| Document notes that procedure and specialty pharmacy codes requiring prior authorization are not available in this document. |
Provider Notification and Prior Authorization Requirements
General prior authorization requirement and contact
Prior authorization is required for certain services to determine medical necessity or whether care is experimental, investigational, or unproven. Verify member eligibility and benefits before requesting authorization. For questions or to obtain prior authorization, contact BCBSNM Health Services at 800-325-8334.
Inpatient admission prior authorization and notification rules
Prior authorization is required for all planned (elective) inpatient hospital care, including surgical, non‑surgical, behavioral health, and substance use admissions; elective admissions must have prior authorization before the admission occurs. For in‑network unplanned or emergency inpatient care, notification of admission to the facility is required; notification is not required for out‑of‑network emergency inpatient care (though it is encouraged).
Outpatient services and pharmacy prior authorization
Prior authorization is required for a range of outpatient services and for certain pharmacy medications per the drug list. Examples of outpatient services that require prior authorization include advanced imaging/radiology, molecular genetic lab testing, musculoskeletal joint and spine surgery, musculoskeletal pain management, radiation oncology, sleep services, and select cardiology, gastroenterology, neurology, pain management, wound care, and selected outpatient surgery procedures. Pharmacy prior authorization requirements apply per the drug list; some specialty pharmacy medications and provider‑administered drug therapies also require medical necessity review.
- Advanced Imaging Radiology (Carelon) and Molecular Genetic Lab Testing (Carelon)
- Musculoskeletal joint and spine surgery, musculoskeletal pain (Carelon)
- Radiation therapy / Radiation Oncology (Carelon) and sleep services (Carelon)
- Select outpatient procedures (cardiology, gastroenterology, neurology, pain management, wound care, select outpatient surgery)
- Pharmacy: prior authorization required on some medications per the drug list; specialty pharmacy medications and provider‑administered therapies may require medical necessity review
Additional ASO services requiring prior authorization
Additional ASO services require prior authorization, including home health (such as private duty nursing and home infusion therapy), home hospice, home hemodialysis, non‑emergent air ambulance, transplant evaluations and transplants, out‑of‑network elective outpatient surgery, and certain mental health/substance use disorder facility admissions and select behavioral health outpatient services.
- Home health services (including private duty nursing/PDN and home infusion therapy)
- Home hospice and home hemodialysis
- Non‑emergent air ambulance
- Transplant evaluations and transplants
- Out‑of‑network outpatient elective surgery
- Mental health and substance use disorder facility admissions and select behavioral health outpatient services
Key Terms
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