CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Prior Authorization Requirements List for Administrative Services Only (ASO) Groups

This document lists services that require prior authorization or recommended clinical review for Blue Cross Blue Shield of New Mexico ASO groups and provides related procedural notes for providers and ASO members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrior Authorization Requirements List for Administrative Services Only (ASO) Groups

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionObtain eligibility and benefits first; prior authorization is required for specified services (including all planned inpatient admissions) before care is provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

01/01/2025policy effective date

InpatientInpatient services

MultipleOutpatient categories

PharmacyPharmacy prior auth

BehavioralBehavioral health

ASO Prior Authorization Criteria

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrior Authorization Requirements List for Administrative Services Only (ASO) Groups

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionObtain eligibility and benefits first; prior authorization is required for specified services (including all planned inpatient admissions) before care is provided.

SourceLink

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ASO Prior Authorization Criteria

Services requiring prior authorization for ASO members effective 01/01/2025 include the following categories. See referenced external code lists and the Blues Provider Reference Manual Section 10 for comprehensive details.

Inpatient Admissions: Prior authorization is required for all planned (elective) inpatient hospital care, including surgical, non-surgical, behavioral health and substance use admissions. In-network unplanned or emergency inpatient care requires notification; out-of-network unplanned or emergency inpatient care notification is encouraged but not required.

Outpatient Medical/Surgical Services

Selected outpatient services require prior authorization. Examples include advanced imaging/radiology, molecular genetic lab testing, musculoskeletal joint and spine surgery and pain procedures, radiation therapy/radiation oncology, and sleep services. Some outpatient reviews are administered through Carelon Medical Benefits Management when applicable.

Home and Ancillary Services

Home health services (including private duty nursing), home hospice, home infusion therapy, home hemodialysis, non-emergent air ambulance, transplant evaluations and transplants, and certain out-of-network elective outpatient surgeries require prior authorization.

Pharmacy and Specialty Drugs

Some medications under pharmacy benefits require prior authorization; specialty pharmacy medications covered by medical benefits require medical necessity review for therapy and place of infusion when applicable. Refer to the downloadable prior authorization/step therapy program information and specialty pharmacy code lists for details.

Behavioral Health Services

Mental health and substance use disorder facility admissions (inpatient, residential treatment centers) require prior authorization. Select outpatient behavioral health services requiring prior authorization or review include applied behavioral analysis (ABA), electroconvulsive therapy (ECT), intensive outpatient treatment, partial hospitalization, psychological/neuropsychological testing, and repetitive transcranial magnetic stimulation (rTMS).

Provider Requirements and Examples

Prior Authorization

Prior Authorization Required

Obtain eligibility and benefits before delivering services to confirm membership, verify coverage, and determine whether prior authorization is required. Prior authorization is required for specified services to determine medical necessity or whether care is experimental, investigational, or unproven per MCG Criteria, BCBSNM Medical Policy, and member benefits. Prior authorization is required for all planned (elective) inpatient hospital care (surgical, non‑surgical, behavioral health and substance use disorder). In‑network unplanned or emergency inpatient care requires notification of admission to the facility; out‑of‑network emergency care notification is encouraged but not required. Verification of eligibility/benefits or prior authorization is not a guarantee of payment — final benefits are determined at claim adjudication based on member eligibility and the certificate of coverage in effect on the date of service. For questions, contact BCBSNM Health Services at 800‑325‑8334.

Prior authorization is required to determine Medical Necessity or Experimental/Investigational/Unproven status.
Obtain eligibility and benefits first to confirm coverage and whether prior authorization is needed.
Prior authorization required for all planned (elective) inpatient admissions; notification required for in‑network unplanned/emergency admissions.

Prior Authorization

Outpatient Prior Authorization Examples

Examples of outpatient services that require prior authorization for ASO members include (when managed by Carelon Medical Benefits Management where indicated): advanced imaging/radiology, molecular genetic laboratory testing, musculoskeletal procedures (joint and spine surgery), musculoskeletal pain procedures, radiation therapy/radiation oncology, and sleep services. These services may be managed through Carelon or directly by BCBSNM depending on the service and contract.

Advanced Imaging / Radiology (Carelon)
Molecular Genetic Lab Testing (Carelon)
Musculoskeletal — Joint and Spine Surgery (Carelon)
Musculoskeletal — Pain (Carelon)
Radiation Therapy / Radiation Oncology (Carelon)
Sleep services (Carelon)

Prior Authorization

Additional Services Requiring Prior Authorization

Additional outpatient and ancillary services that require prior authorization for ASO members include home health (including private duty nursing), home hospice, home infusion therapy, home hemodialysis, non‑emergent air ambulance, transplant evaluations and transplants, out‑of‑network/out‑of‑plan elective outpatient surgery, select outpatient specialties and procedures (for example certain cardiology services such as lipid apheresis; ENT; gastroenterology; neurology; selected outpatient surgeries such as breast procedures, deactivation of headache triggers, jaw surgery; pain management; and wound care). Pharmacy benefits may also require prior authorization for certain medications and specialty pharmacy medications covered under medical benefits may require medical necessity review (including infusion site of care and provider‑administered drug therapies).

Home Health Services (including private duty nursing)
Home Hospice
Home Infusion Therapy (HIT)
Home Hemodialysis
Non‑Emergent Air Ambulance
Transplant Evaluations and Transplants
Out‑of‑Network/Out‑of‑Plan elective outpatient surgery
Select Outpatient Services (e.g., cardiology — lipid apheresis; ENT; gastroenterology; neurology; select outpatient surgeries; pain management; wound care)
Pharmacy: Prior authorization may be required for some medications; specialty pharmacy/medical oncology drugs may require medical necessity review (including infusion site of care and provider‑administered therapies)

Key Definitions

Definition — Prior Authorization

DefinitionPrior Authorization is a preservice review required in advance to determine medical necessity or whether care is experimental, investigational or unproven, using MCG Criteria, Medical Policy, and member benefits.

TimingMust be obtained in advance for services designated as requiring prior authorization (elective/planned inpatient admissions and specified outpatient services).

PurposeTo assess benefits and medical necessity and to identify Experimental, Investigational and/or Unproven care prior to service delivery.

Definition — Recommended Clinical Review

DefinitionRecommended Clinical Review is a preservice review that is elective for services that do not require prior authorization.

Relation to prior authBCBSNM uses both prior authorization (required for certain services) and recommended clinical review (elective); similarities predominate between them but requirement is the key difference.

Provider actionProviders may choose to request a recommended clinical review for services not listed as requiring prior authorization to confirm benefits or appropriateness.

OpenPayer

Prior Authorization Requirements List for Administrative Services Only (ASO) Groups

ASO Prior Authorization Criteria

Procedure and Code Information

Provider Requirements and Examples

Key Definitions