Procedures Requiring Prior Authorization
A list of CPT/HCPCS codes and service categories for which Blue Cross Blue Shield of New Mexico requires prior authorization for certain commercial (non‑HMO) membership products; applies to providers submitting claims and requesting authorizations for covered members.
No material clinical or coverage changes in this revision.
Prior Authorization Requirements
General prior authorization and program requirements
Covered when the prior authorization list and program requirements are met:
ALL of the following
- Inclusion on the prior authorization list does not guarantee coverage; member benefits and eligibility govern payment determinations.
- Prior authorization must be obtained when indicated; services performed without required prior authorization may be denied for payment and providers may not seek reimbursement from members.
- Providers must verify eligibility and benefits for each patient prior to rendering services; use the Availity Provider Portal or other preferred vendor portals to check eligibility/benefits and submit requests.
- Some prior authorization requests must be submitted to Blue Cross and Blue Shield of New Mexico (BCBSNM); others must be submitted to designated utilization management vendors as specified.
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