CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

2025 Commercial Outpatient Behavioral Health Prior Authorization Codes

List of CPT/HCPCS procedure codes and service descriptions for which prior authorization may be required for Blue Cross and Blue Shield of New Mexico commercial outpatient behavioral health networks and guidance on the utilization management process; applies to affected BCBSNM providers and members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2025 Commercial Outpatient Behavioral Health Prior Authorization Codes

Policy CodePolicy N/A

Change TypeTechnical/code list update (no material clinical changes)

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionVerify member eligibility and benefits via Availity or the preferred portal and request prior authorization when required before rendering services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/1/2025effective date for the code list

36rTMS sessions/course

20+PHP minimum weekly hours

Searchable PDFdocument format

Multipleprior auth vendors

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prior Authorization & Coverage Notes

Prior authorization and coverage notes

Prior authorization and coverage disclaimers

ALL of the following

Prior authorization is required for some members, services, and drugs before services are rendered to confirm medical necessity as defined by the member's health benefit plan.
A prior authorization is not a guarantee of benefits or payment; the member's plan controls available benefits.
The provider is usually responsible for requesting prior authorization before performing a service if the member is seeing an in-network provider. Some plans may require the member to request prior authorization.
Once a prior authorization request is received and processed, the decision is communicated to the provider.
Obtaining prior authorization is not a substitute for checking eligibility and benefits.
Always check eligibility and benefits first through Availity Essentials (availity.com) or your preferred web vendor portal to confirm coverage, prior authorization or pre-notification requirements, and vendor information.
The presence of procedure or diagnosis codes on any sample or guidance list does not guarantee coverage under a member's benefits contract.
This is not an exhaustive list; codes may change and lists may be updated throughout the year. Member contracts differ — always verify eligibility and benefits.
For some services/members, prior authorization may be managed directly by Blue Cross and Blue Shield of New Mexico (BCBSNM); for other services/members, BCBSNM has contracted with Carelon Medical Benefits Management for utilization management and related services.
If you have questions, call the prior authorization number on the member's ID card or use the appropriate vendor portal.
Availity is a trademark of Availity, LLC, a separate company that provides electronic information exchange services and administrative services to BCBSNM.
Use Availity Essentials or your preferred web vendor portal to confirm coverage details and prior authorization requirements.

Procedure Codes, Typical Course & Program Hours

Behavioral health CPT/HCPCS codes subject to prior authorizationmixed

97151	Applied Behavior Analysis (ABA) - Bhv Id Assmt By Phys/Qhp
97152	Applied Behavior Analysis (ABA) - Bhv Id Suprt Assmt By 1 Tech
97153	Applied Behavior Analysis (ABA) - Adaptive Behavior Tx By Tech
97154	Applied Behavior Analysis (ABA) - Grp Adapt Bhv Tx By Tech
97155	Applied Behavior Analysis (ABA) - Adapt Behavior Tx Phys/Qhp
97156	Applied Behavior Analysis (ABA) - Fam Adapt Bhv Tx Gdn Phy/Qhp
97157	Applied Behavior Analysis (ABA) - Mult Fam Adapt Bhv Tx Gdn
97158	Applied Behavior Analysis (ABA) - Grp Adapt Bhv Tx By Phy/Qhp
0362T	Applied Behavior Analysis (ABA) - Bhv Id Suprt Assmt Ea 15 Min
0373T	Applied Behavior Analysis (ABA) - Adapt Bhv Tx Ea 15 Min

1–10 of 31

1/4

rTMS typical course sessions

Typical rTMS treatment course (sessions)Usually 1 daily session, 5 days per week for up to 6 weeks (initial phase), followed by a 3-week taper: 3 sessions in week 1, 2 sessions in week 2, and 1 session in week 3 — total of 36 sessions. Course may be repeated after a 6-month cessation period if needed.

Partial Hospitalization program hours

Partial Hospitalization program hoursTypically 5 to 8 hours per day, 5 days per week (not less than 20 hours of treatment services per week). Program must be licensed or nationally accredited and provide weekly face-to-face psychiatrist contact.

ECT outpatient frequency after step-down

ECT outpatient frequency after step-downECT is typically administered 2-3 times per week while inpatient; after stepping down to outpatient care, frequency may change to once every 3-4 weeks.

Prior Auth Steps, Verification & UM Vendors

Prior Authorization

Prior authorization requirements and provider responsibilities

Prior authorization is required for some members/services before services are rendered to confirm medical necessity as defined by the member's health benefit plan. A prior authorization is not a guarantee of benefits or payment. Usually the provider is responsible for requesting prior authorization for in-network services; sometimes the plan may require the member to request authorization. Once a request is processed the decision is communicated to the provider. If questions, call the prior authorization number on the member's ID card.

Prior authorization confirms medical necessity per the member's plan but does not guarantee payment.
Provider usually must request authorization before performing a service for in-network members.
Decisions are communicated to the provider after processing; use the number on the member ID card for questions.

Documentation Required

How to verify codes, eligibility, and benefits

Program & Treatment Definitions

Partial Hospitalization Treatment Program (PHP)

DefinitionPartial Hospitalization Treatment Program (PHP): a Claim Administrator–approved planned program in a hospital or SUD treatment facility for mental illness or substance use disorder treatment

Typical scheduleTypically 5–8 hours per day, 5 days per week (not less than 20 hours/week)

Level-of-care characteristicsStaffed like an inpatient day shift; medically supervised by physician and nurse; participants do not require 24-hour supervision

Psychiatry involvementPsychiatrist must see the patient face-to-face at least once a week and be available as needed

Applied Behavior Analysis (ABA)

DefinitionApplied Behavior Analysis (ABA): a method of therapy used to improve or change specific behaviors for members with diagnoses within the pervasive and specific developmental disorders category (ICD-10)

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2025 Commercial Outpatient Behavioral Health Prior Authorization Codes

Policy CodePolicy N/A

Change TypeTechnical/code list update (no material clinical changes)

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionVerify member eligibility and benefits via Availity or the preferred portal and request prior authorization when required before rendering services.

SourceLink

On This Page

This file is a searchable PDF — use CTRL+F to locate procedure codes or service descriptions. Always check eligibility and benefits first through Availity® Essentials (availity.com) or your preferred vendor portal to confirm coverage, prior authorization or pre-notification requirements, and the appropriate utilization management vendor before requesting authorization.

Use the PDF search box (CTRL+F) to find procedure codes or descriptions.
Verify eligibility and benefits via Availity Essentials or preferred portal before requesting prior authorization.
Obtaining prior authorization is not a substitute for checking eligibility and benefits.

Note

Third-party utilization management and vendor responsibility

Some prior authorizations are handled directly by BCBSNM; others are managed by Carelon Medical Benefits Management per contracted arrangements. Contact numbers for prior authorization are shown on the member's ID card.

BCBSNM administers prior authorization for some services/members.
Carelon Medical Benefits Management provides utilization management services for other services/members under contract with BCBSNM.
BCBSNM does not endorse products or services provided by third-party vendors.

Care contextProvided as behavioral therapy focused on specific behavior change goals

Intensive Outpatient Program (IOP)

DefinitionIntensive Outpatient Program (IOP): freestanding or hospital-based program providing services at least 3 hours/day for two or more days/week to treat mental illness and/or substance use disorders

Program featuresMay offer integrated assessment, treatment, and discharge planning for co-occurring conditions

Repetitive Transcranial Magnetic Stimulation (rTMS)

DefinitionRepetitive Transcranial Magnetic Stimulation (rTMS): a form of brain stimulation therapy used to treat psychiatric conditions in a facility/clinic setting

Typical course1 daily session, 5 times/week for up to 6 weeks, followed by a 3-week taper for a total of 36 sessions

Administration constraintCannot be administered on the same day as PHP, IOP, ECT, or ABA care-level services

Course repetitionCourse may be repeated after a 6-month cessation period if needed

Electroconvulsive Therapy (ECT)

DefinitionElectroconvulsive Therapy (ECT): brief electrical stimulation of the brain under anesthesia to treat severe psychiatric disorders and billed by a facility/clinic

Inpatient administration frequencyTypically administered 2–3 times per week if the member is admitted to an inpatient care level

Outpatient maintenance frequencyOnce the member steps down to outpatient care, frequency may change to once every 3–4 weeks