CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Commercial Outpatient Prior Authorization Procedure Code List

Governs prior authorization requirements and initiation methods for selected outpatient procedure and service codes for Blue Cross Blue Shield of New Mexico commercial (including ASO) members; affects providers submitting prior authorization requests.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCommercial Outpatient Prior Authorization Procedure Code List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionInitiate prior authorization via Availity's Authorizations tool or call the number on the member's ID card; for Carelon-handled services call Carelon or use their portal.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleprocedure codes listed for prior authorization

2ways to initiate prior authorization

multipledistinct routing destinations referenced

~80+discrete CPT/HCPCS and molecular/genetic codes listed

07/01/2023codes with add effective date

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Prior Authorization and Routing Criteria

Prior authorization is required for certain outpatient services and select procedure codes. Requirements vary by product and may be managed by BCBSNM or delegated vendors (Carelon Medical Benefits Management). Verify member benefits and the appropriate review entity before submitting a request.

title':'Prior authorization verification and requirements','type':'criteria_group'

nodes_versioned_only_removed_do_not_use_here?true

Code Lists and Routing Tables

Advanced Imaging / Radiology (Carelon)HCPCS

A9602

Fluorodopa F-18, Diagnostic, Per Millicurie

Molecular Genetic Lab Testing (Carelon)CPT

81418	Molecular Genetic Lab Testing (example entries added 07/01/2023)
0332U	Onc Pan Tum Gen Prflg 8 Dna (example molecular/genetic U-code)

Advanced Imaging / Radiology (Carelon)CPT

70460	CT Head/Brain (with/without dye) — Advanced Imaging
70540	MRI Orbit/Face/Neck W/O Dye — Advanced Imaging
71260	CT Thorax

Sample CPT/HCPCS mappings to internal routingmixed

73701	MRI Lower Extremity (mapped to Advanced Imaging / Radiology and Carelon in routing)
74160	CT/MRI abdomen series (multiple mappings to Advanced Imaging / Radiology and Carelon)
74261	CT Colonography (mapped to Advanced Imaging / Radiology and Carelon)

Non-imaging procedure mappingsmixed

36516	Apheresis (mapped to BCBSNM)
30120	Revision of nose (mapped to BCBSNM / ENT)

Molecular/genetic test codesCPTCovered

81120-81306 (many individual codes listed)

Molecular genetic lab testing CPT codes (examples: BRCA1/2, APC, CFTR, many gene-specific analyses) routed primarily to Carelon

Hearing device HCPCSHCPCSCovered

L86xx, L869x

Cochlear implant external processor and accessory HCPCS codes routed to BCBSNM

Sample molecular genetic CPT mappingsCPT

81285	Alleles (mapped to Carelon)
81286	Molecular genetic lab testing; Fxn Gene Full Gene Sequence (mapped to Carelon)
81287	Molecular genetic lab testing; Mgmt Gene Prmtr Mthyltn Alys (mapped to Carelon)
81288	Molecular genetic lab testing; Mlh1 Gene (mapped to Carelon)
81289	Molecular genetic lab testing; Fxn Gene Known Famil Variant (mapped to Carelon)
81290	Molecular genetic lab testing; Mcoln1 Gene (mapped to Carelon)
81291	Molecular genetic lab testing; Mthfr Gene (mapped to Carelon)
81292	Molecular genetic lab testing; Mlh1 Gene Full Seq (mapped to Carelon)

Additional molecular/onco code mappingsCPT

81416	Exome Sequence Analysis / Exome Re-Evaluation (mapped to Carelon)
81425	Fetal Chromosomal Microdeletion / Genome Sequence Analysis (mapped to Carelon)
81504	Oncology Tissue Of Origin (mapped to Carelon)
81518	Onc Breast mRNA 11 Genes (mapped to Carelon)

PLA/U codesmixed

0005U	Onco Prst8 3 Gene Ur Alg (mapped to Carelon)
0014U	Hem Hmtlmf Neo Gene Reargmt (mapped to Carelon); code termed effective 1/1/2023 noted
0036U	Xome Tum & Nml Spec Seq Alys (mapped to Carelon)
0048U	Onc Sld Org Neo Dna 468 Gene (mapped to Carelon)

Sample U-codes and descriptions (many more follow in document)mixed

0048U	Molecular Genetic Lab Testing / Onc Sld Org Neo Dna 468 Gene
0049U	Molecular Genetic Lab Testing / Npm1 Gene Analysis Quan
0050U	Molecular Genetic Lab Testing / Trgt Gen Seq Dna 194 Genes

Additional notable codesmixed

0306U	Oncology (Minimal Residual Disease), Next-Generation Targeted Sequencing Analysis, Cell-Free DNA, Initial Assessment
0307U	Oncology (Minimal Residual Disease), Next-Generation Targeted Sequencing Analysis, Cell-Free DNA, Subsequent Assessment
G9143	Warfarin Response Genetic Test

Musculoskeletal_Joint, Spine Surgery group mappingsCPT | HCPCS | mixed

20930-20938, 20974	Spine and bone graft related procedure codes mapped to Musculoskeletal_Joint, Spine Surgery
22206-22226	Inclusion of multiple spinal incision/osteotomy codes mapped to Musculoskeletal_Joint, Spine Surgery
22510-22556, 22585	Percutaneous vertebral augmentation and related spine procedure codes
22600-22634, 22800-22864	Various posterior thoracolumbar fusion and fixation codes
27120-27138, 27279	Hip reconstruction and sacroiliac procedures
27332-27488	Knee/cartilage procedures including arthroplasty and revisions
28446	Osteochondral talus autograft
62380, 63003-63005	Spinal decompression/lamina removal related codes

Molecular genetic and lab testing codesHCPCS | mixed

0319U-0327U, 0326U, 0327U	Molecular genetic lab testing and specialized assay codes (including transplant and risk score assays)
G9143, S3800-S3866, S3870, S3840-S3854, S3861, S3865	Various molecular genetic / gene test HCPCS codes mapped to genetic testing categories

Partial code routing map from document segmentmixed

27416-27488 (example range shown)	Knee procedures and related codes mapped to Carelon in this excerpt
63003-63103 (example range shown)	Spine lamina/laminotomy/related codes mapped to Carelon
62320-63688 (example range shown)	Interventions for spinal pain and implants mapped to Carelon
0098T, 0163T	Codes noted as terminated 12/31/2022 and replaced by 22860
A4290, E0745, A0430, A0435, 19316, 19318	Various HCPCS/CPT items mapped to BCBSNM in neurology/outpatient surgery contexts

codes_routedmixed

19294-19298, 20555, 31643, 32701, 41019, 55860-55875, 55920, 57155-57156	Radiation therapy / radiation oncology related CPT codes listed and mapped to Carelon for prior authorization
A9508, A9513, A9528, A9531, A9543, A9590, A9600-A9607	HCPCS/Rx codes for radionuclide therapies mapped to Carelon
G0340, G0458, G6001-G6017, Q3001, S8030	G-/Q-/S- codes related to radiation therapy and robotics mapped to Carelon
64582-64584, 95782-95783, 95800-95806, A4604, A7027	Neurostimulator and sleep study codes mapped to Carelon

Sample procedure code routingCPTCovered

G6014	Radiation Treatment Delivery — routing shown to Carelon
G6015	Radiation Therapy / Radiation Oncology — routing shown to Carelon
95807	Sleep Study Attended — Carelon or BCBSNM
32851	Lung Transplant, Single — Carelon/BCBSNM indicated

Code termination note

Termination note textSome PLA/U codes in the list are documented as 'Code Termed Effective 1/1/2023'.

Example code with termination note0014U — annotated in the list with 'Code Termed Effective 1/1/2023'.

Scope of termination noteTermination annotations appear alongside PLA/U and select molecular genetic U-codes in the code lists.

patient-specific panel use

Intended use0306U (Initial baseline) — 'Targeted Sequencing Analysis, Cell‑Free DNA, Initial (Baseline) Assessment to determine a patient specific panel for future comparisons to evaluate for MRD'.

Subsequent assessment code0307U — 'Next‑Generation Targeted Sequencing Analysis of a patient‑specific panel, Cell‑Free DNA, Subsequent Assessment with comparison to previously analyzed patient specimens to evaluate for MRD'.

PurposeEstablish a patient‑specific baseline panel for future Minimal Residual Disease (MRD) comparisons and monitoring.

How to Initiate Prior Authorization and Routing Guidance

Prior Authorization

How to initiate prior authorization

Registered Availity users may submit prior authorization requests using Availity's Authorizations tool (HIPAA-standard 278 transaction); alternatively, call the prior authorization number on the member's ID card. For services handled by Carelon, call 1-866-455-8415 or access the Carelon website.

Use Availity Authorizations tool (HIPAA 278) or phone for BCBSNM-handled requests.
For Carelon-managed services, call 1-866-455-8415 or use Carelon portal.

Prior Authorization

Care categories requiring prior authorization for ASO members

The following care categories require prior authorization through Carelon for all ASO members: Molecular Genetic Lab Testing; Radiation Therapy / Radiation Oncology; Advanced Imaging / Radiology; Musculoskeletal - Pain; Musculoskeletal - Joint, Spine Surgery.

Prior Authorization

Key Terms and Vendor Definitions

Administrative Services Only (ASO)

DefinitionAdministrative Services Only (ASO): group of members/products for which Carelon handles prior authorization for specified care categories (e.g., Molecular Genetic Lab Testing, Radiation Therapy, Advanced Imaging, Musculoskeletal - Pain, Musculoskeletal - Joint/Spine Surgery).

Implication for providersProviders must verify preauthorization requirements for ASO members via Availity, since not all requirements apply to every product/network.

Note on coveragePresence on the code list does not guarantee coverage; consult member benefit booklet or customer service.

Availity (HIPAA 278 web tool)

Tool nameAvaility Authorizations tool (web-based, supports HIPAA-standard 278 transactions).

How to access

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCommercial Outpatient Prior Authorization Procedure Code List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionInitiate prior authorization via Availity's Authorizations tool or call the number on the member's ID card; for Carelon-handled services call Carelon or use their portal.

SourceLink

On This Page

Additional potentially-required categories

Additional outpatient care categories may require prior authorization for ASO members (availability varies by product/network); providers must verify preauthorization requirements through Availity. Examples include Sleep and select outpatient procedures (cardiology - lipid apheresis, ENT, gastroenterology, neurology outpatient surgery, pain management, wound care).

Not all requirements apply to every product (PPO, EPO, HMO); check member benefits.
Providers should verify via Availity eligibility and preauthorization requirements.

Prior Authorization

Initiating prior authorization

For BCBSNM-handled prior authorization requests, providers may either submit electronically through Availity's Authorizations tool or call the prior authorization number listed on the member's ID card; refer to the Availity Authorizations User Guide for instructions.

Documentation Required

Code-to-authorizer routing

This document maps many CPT/HCPCS and molecular/genetic codes to the entity that handles prior authorization (primarily Carelon or BCBSNM); providers must route requests to the indicated authorizer for the listed codes.

Example routed codes include G0235 → Carelon and 36516 → BCBSNM.
Large blocks of molecular genetic CPT codes (e.g., 81285–81306) are routed to Carelon.

Prior Authorization

How to initiate prior authorization

Providers may initiate prior authorization for BCBSNM-handled services either via Availity's Authorizations tool (HIPAA 278) or by calling the number on the member's ID card; for Carelon-managed services, use Carelon's web portal or phone line.

Prior Authorization

Initiating prior authorization

For BCBSNM-handled requests the two initiation methods are (1) Availity Authorizations tool (HIPAA 278) for registered users and (2) calling the prior authorization number on the member ID card; Carelon-managed services have separate contact details and a Carelon portal.

Refer to the Availity Authorizations User Guide for submission instructions.
Carelon web portal URL and phone are provided for Carelon-managed services.

Prior Authorization

How to initiate prior authorization

When a code is listed as managed by Carelon, prior authorization must be processed through Carelon (portal or phone) rather than BCBSNM; follow the routing indicated in the code list for each CPT/HCPCS or U/PLA code.

Examples: 0048U → Carelon; 81286 → Carelon.

Prior Authorization

Carelon routing for listed codes

Carelon is the delegated reviewer for many listed molecular/genetic and advanced imaging codes; utilize Carelon's Healthcare Web Portal (available 24/7) or call the Carelon phone line for case initiation and status checks.

Carelon web portal: https://Carelonspecialtyhealth.com
Carelon phone: 1-866-745-1789 (hours noted)

Prior Authorization

Routing table excerpt — musculoskeletal/joint/spine and related codes

Musculoskeletal, joint and spine procedure codes in the list are routed primarily to Carelon for prior authorization; providers must submit authorization requests to the designated handler shown in the routing table for codes such as 27416, 27425, 27427 and spine ranges (e.g., 22800–22810).

Example: 27416 → Carelon.
Spine procedure ranges (22800 series) → Carelon.

Documentation Required

PA routing by code (partial)

The code-to-authorizer routing excerpt shows specific examples where BCBSNM or Carelon is assigned; providers must follow the listed mapping when initiating prior authorization for those codes.

Example: 30130 and related neurology/outpatient surgery codes → BCBSNM.
Example: G0235 and many molecular codes → Carelon.

Prior Authorization

Initiating prior authorization requests

Initiate prior authorization requests for BCBSNM-handled services via Availity Authorizations (HIPAA 278) or by phone using the number on the member's ID card; for codes handled by Carelon, use Carelon's contact methods as listed in the policy.

Documentation Required

Vendor routing examples

Vendor routing examples in the list show some codes may be routed to either Carelon or BCBSNM; for example, sleep study codes 95807 and 95808 are noted as routed to Carelon or BCBSNM — providers must verify the correct route for the member and code before submitting.

95807 and 95808 are indicated as 'Carelon or BCBSNM' in the routing table.

Note

Eligibility and vendor disclaimer

Checking eligibility or that a service has been prior authorized is not a guarantee of payment; benefits are determined at claim receipt and are subject to the member's coverage. BCBSNM makes no endorsement or warranty regarding third-party vendors such as Availity or Carelon.

Verify coverage via member benefit booklet or customer service; prior authorization does not guarantee payment.
BCBSNM disclaims endorsement of third-party vendors.

Registered Availity users may use the Availity Authorizations tool; refer to the Availity Authorizations User Guide for instructions.

AlternativeCall the prior authorization number on the member's ID card if not using Availity.

Carelon

OrganizationCarelon Medical Benefits Management (formerly AIM Specialty Health) — delegated prior authorization vendor and portal operator referenced for many listed codes.

Portal/phoneCarelon web portal (Carelonspecialtyhealth.com) and phone numbers provided for case initiation and status (portal preferred; phone numbers in document).

RoleHandles prior authorization routing and utilization management for multiple service categories (e.g., Advanced Imaging, Molecular Genetic Lab Testing).

Advanced Imaging / Radiology

Service categoryAdvanced Imaging / Radiology — listed as a managed category and mapped for PA routing (examples: A9602, 70460, 70540, 71260).

RoutingMany advanced imaging CPT/HCPCS entries in the list are routed to Carelon for prior authorization.

InitiationUse Carelon portal or call Carelon (portal available 24/7); for BCBSNM‑handled items use Availity or the phone number on the member ID.

Carelon (delegated reviewer for molecular genetic codes)

DelegationCarelon is repeatedly listed as the delegated prior authorization reviewer/vendor for many molecular genetic and laboratory testing codes.

ExamplesLarge blocks of molecular genetic CPT and HCPCS codes (e.g., 81120–81306, S38xx series, many U‑codes) indicate 'Carelon = Carelon' routing.

How to requestFor Carelon‑managed molecular/genetic tests, initiate via the Carelon portal or call the Carelon phone number provided.

Blue Cross Blue Shield of New Mexico (BCBSNM)

Payer roleBlue Cross Blue Shield of New Mexico (BCBSNM) — listed as the prior authorization handler for select codes and procedure types routed to BCBSNM.

ExamplesSelected codes (e.g., 36516 Apheresis; 30120/304xx ENT procedures; select neurology/implant codes) are mapped to BCBSNM rather than Carelon.

Provider actionFor BCBSNM‑handled requests initiate via Availity or call the prior authorization number on the member's ID card.

Delegated prior authorization reviewer (molecular/genetic codes)

Delegated reviewer identityCarelon is identified repeatedly as the delegated prior authorization reviewer/vendor for many molecular genetic CPT and HCPCS codes.

Coverage mappingBlocks of genetic testing codes (e.g., 81285–81297 series, many U‑codes) show 'Carelon = Carelon' indicating Carelon handles PA review.

Provider initiationProviders should use Carelon's web portal or phone to submit prior authorization requests for these delegated codes.

Carelon (external prior authorization vendor)

Carelon referenceCarelon Medical Benefits Management (formerly Carelon Specialty Health/AIM) — referenced repeatedly as the external prior authorization vendor.

Portal URLCarelon web portal URL shown in document: https://Carelonspecialtyhealth.com (portal recommended for case initiation and status).

Phone numbersCarelon phone contacts appear for different workflows (e.g., 1-866-455-8415 for Carelon services; a portal/toll‑free number also listed).

MRD targeted sequencing

Test typeMRD targeted sequencing: 'Targeted Sequencing Analysis, Cell‑Free DNA, Initial (Baseline) Assessment to determine a patient specific panel for future comparisons to evaluate for MRD' (0306U).

Associated codes0306U (initial baseline) and 0307U (subsequent assessment) are explicitly described as MRD‑related targeted sequencing analyses.

Intended useUsed to establish and compare patient‑specific panels for evaluation of Minimal Residual Disease (MRD).

Carelon (processing for listed codes)

Carelon roleCarelon is the vendor handling prior authorization for many listed codes (document uses 'Carelon = Carelon' to indicate processing by Carelon).

Documented instructionUtilizing the Carelon Healthcare Web Portal is noted as the most efficient way to initiate a case, check status and view guidelines.

24/7 portalCarelon web portal availability is noted (portal available 24/7).

Musculoskeletal_Joint, Spine Surgery

Procedure groupMusculoskeletal_Joint, Spine Surgery — grouping used to categorize many listed CPT codes (e.g., ranges 20930–20938, 22206–22226, 22510–22556, 22600–22634).

RoutingMany musculoskeletal and spine procedure codes are routed to Carelon for prior authorization review.

ExamplesKnee and spine procedure code ranges and specific codes (e.g., 27416 series, 22533–22556, 22600–22632) appear in the routing tables.

Prior authorization review entity contracted by BCBSNM

PA review entityCarelon is the prior authorization review entity contracted by BCBSNM and is listed as the handler for many procedure codes.

BCBSNM handled exceptionsCertain codes (notably some neurology/implant and transplant related codes) are routed to BCBSNM rather than Carelon.

Eligibility disclaimerChecking eligibility or prior authorization is not a guarantee of payment; benefits determined when a claim is received.

Blue Cross Blue Shield of New Mexico (handler for select codes)

Payer mappingBCBSNM is listed as the handler for select codes in the excerpt (examples include ENT, neurology/implant and selected outpatient surgery/jaw codes).

ExamplesCodes such as 30120, 30400–30450 (ENT/revision/reconstruction of nose) and various jaw surgery codes (21145–21160 series) map to BCBSNM.

Provider actionInitiate BCBSNM‑handled prior authorizations via Availity or by calling the number on the member's ID card.

Carelon (radiation oncology reviewer)

Carelon delegationCarelon is indicated as the delegated prior authorization reviewer for many radiation oncology and related codes in the document.

ExamplesRadiation therapy CPT and HCPCS codes and radionuclide therapy HCPCS (e.g., 19298 series, A9600–A9607, A9543, A9590) show Carelon routing.

Portal guidanceFor Carelon‑routed radiation oncology cases, use the Carelon portal or designated Carelon phone contact.

BCBSNM (Blue Cross Blue Shield of New Mexico)

BCBSNM roleBCBSNM (Blue Cross Blue Shield of New Mexico) handles prior authorization for listed codes where the routing indicates 'BCBSNM = BCBSNM'.

ExamplesNeurology and select outpatient surgery/jaw codes (e.g., 21145–21160, 30130–30140 series) are routed to BCBSNM in the excerpt.

Provider initiationFor BCBSNM‑handled items, initiate via Availity Authorizations tool or call the PA number on the member's ID card.

Carelon (repeated reference)

Carelon reference repeatedCarelon is cited repeatedly across code tables as the authorization handler for many CPT/HCPCS and molecular genetic codes.

Carelon contactCarelon phone (1-866-455-8415) and portal instructions are provided for services handled by Carelon.

Delegated reviewCarelon performs utilization management and prior authorization review as contracted by BCBSNM.

Availity

DefinitionAvaility: a separate company providing electronic information exchange services; Availity provides administrative services to BCBSNM and offers the Authorizations tool.

UsageRegistered Availity users may use the Availity Authorizations tool (HIPAA 278) to initiate prior authorization requests handled by BCBSNM.

DisclaimerBCBSNM makes no endorsements or warranties regarding third‑party vendors such as Availity.