CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Procedures Requiring Prior Authorization

A list of CPT/HCPCS codes and service categories for which prior authorization may be required for specified commercial non-HMO members; explains provider responsibilities for verifying eligibility and obtaining prior authorization.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyProcedures Requiring Prior Authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionProviders must check member eligibility and benefits before services and obtain required prior authorization through BCBSNM or designated vendors.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2023-01-01effective date

commercial non-HMOproduct scope

multiplecodes listed

36 sessionsrTMS course

Prior Authorization and Coverage Criteria

Prior authorization applicability and coverage determination

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyProcedures Requiring Prior Authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionProviders must check member eligibility and benefits before services and obtain required prior authorization through BCBSNM or designated vendors.

SourceLink

On This Page

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.

ALL of the following

Codes on this list may require prior authorization for some commercial non-HMO members; the presence of a code does not indicate coverage under the member's benefits contract.
Providers must verify member eligibility and benefits prior to rendering services and confirm whether prior authorization is required and which utilization management vendor (if any) must be used.
Prior authorization for some services/categories must be obtained through Blue Cross and Blue Shield of New Mexico (BCBSNM); prior authorization for other services/categories must be obtained through a utilization management vendor as specified.
Services performed without required prior authorization will be denied for payment and providers may not seek reimbursement from BCBSNM members.
Checking eligibility and/or the fact that a service has been prior authorized is not a guarantee of payment; payment is determined at claim adjudication based on member eligibility and the member's certificate of coverage on the date of service.
Providers may submit online eligibility and benefits inquiries via the Availity Provider Portal or other preferred web vendor portal.

Effective date: January 1, 2023 (list updated periodically).

Codes Requiring Prior Authorization

CPT codes requiring prior authorizationCPT

97151	Behavior Identification Assessment by Physician/Qualified Health Professional (ABA)
97152	Behavior Identification Support Assessment by Technician (ABA)
97153	Adaptive Behavior Treatment by Technician (ABA)
97154	Group Adaptive Behavior Treatment by Technician (ABA)
97155	Adaptive Behavior Treatment by Physician/Qualified Health Professional (ABA)
97156	Family Adaptive Behavior Treatment Guidance by Physician/Qualified Health Professional (ABA)
97157	Multiple-Family Adaptive Behavior Treatment Guidance (ABA)
97158	Group Adaptive Behavior Treatment by Physician/Qualified Health Professional (ABA)
96105	Assessment of Aphasia, per hour (Psychological/Neuropsychological Testing)
96110	Developmental Screening, per instrument

1–10 of 26

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Provider Responsibilities and Notices

Prior Authorization

Obtain prior authorization and verify benefits before services

Prior authorization may be required for the CPT/HCPCS codes and service categories listed; providers must check member eligibility and benefits prior to rendering services and obtain prior authorization through BCBSNM or the specified utilization management vendor when required. Services performed without required prior authorization will be denied for payment and providers may not seek reimbursement from members.

Verify eligibility and benefits (electronic 270 via Availity Provider Portal or other vendor portals) before providing services.
Obtain prior authorization from BCBSNM or the designated utilization management vendor when the service/category requires it.

Documentation Required

Authorization is not a guarantee of payment

Checking eligibility and obtaining prior authorization does not guarantee payment; final benefits and payment are determined at claim adjudication based on the member's eligibility and certificate of coverage on the date services were rendered. For questions, contact the phone number on the member's ID card.

Prior authorization is not a substitute for verifying member eligibility and benefits.
If payment questions remain, use the contact number on the member's ID card.

Program and Treatment Definitions

inv-05: Applied Behavior Analysis (ABA)

DefinitionApplied Behavior Analysis (ABA): a method of therapy used to improve or change specific behaviors for members with diagnoses in the Pervasive and Specific Developmental Disorders category of ICD-10.

Typical billing/codingCodes on the list include ABA-related CPT codes such as 97151–97158 and timed procedure codes 0362T, 0373T (see coding list).

Care-level restrictionrTMS cannot be administered on the same day as ABA services (care-level conflict).

Actionable requirementPrior authorization may be required for ABA services for specified commercial non-HMO members; providers must verify member eligibility/benefits and obtain authorization per BCBSNM procedures.

inv-06: Intensive Outpatient Program (IOP)

DefinitionIntensive Outpatient Program (IOP): a freestanding or hospital-based program providing services at least 3 hours/day, two or more days/week for treatment of mental illness, substance use disorders, or co-occurring conditions.

Program focusMay specialize in integrated treatment of severe or complex co-occurring mental illness and substance use conditions with aligned assessment, treatment and discharge planning.

Care-level restrictionrTMS cannot be administered on the same day as IOP services (care-level conflict).

Actionable requirementPrior authorization may be required for IOP services for specified commercial non-HMO members; providers must verify eligibility/benefits and obtain authorization per BCBSNM procedures.

inv-07: Partial Hospitalization Treatment Program (PHP)

DefinitionPartial Hospitalization Treatment Program (PHP): a planned program (hospital or SUD treatment facility) typically 5–8 hours/day, 5 days/week (not less than 20 hours/week) for treatment of mental illness or substance use disorder.

Staffing and oversightProgram is staffed similarly to inpatient day shift, medically supervised by a physician and nurse; psychiatrist must see the patient face-to-face at least weekly and be available as needed.

Licensing/credentialingPHP must be licensed in the state where located or accredited by a national organization recognized by the Claim Administrator and meet credentialing requirements.

Actionable requirementPrior authorization may be required for PHP services for specified commercial non-HMO members; providers must verify eligibility/benefits and obtain authorization per BCBSNM procedures.

inv-08: rTMS

DefinitionRepetitive Transcranial Magnetic Stimulation (rTMS): a form of brain stimulation therapy delivered in a facility/clinic setting for psychiatric conditions.

Typical treatment courseUsually 1 session/day, 5 days/week for up to 6 weeks followed by a 3-week taper (3 sessions week 1, 2 sessions week 2, 1 session week 3) — total of 36 sessions; course may be repeated after a 6-month cessation period.

Care-level restrictionrTMS cannot be administered on the same day as PHP, IOP, ECT, or ABA care-level services.

SettingAdministered in a facility/clinic setting; prior authorization may be required for specified commercial non-HMO members.

inv-09: Electroconvulsive Therapy (ECT)

DefinitionElectroconvulsive Therapy (ECT): brief electrical stimulation of the brain administered while the member is under anesthesia to treat severe psychiatric disorders; billed by a facility/clinic.

Usual frequencyTypically administered 2–3 times per week if member is inpatient; frequency may change to once every 3–4 weeks when on outpatient care level.

Care-level restrictionrTMS cannot be administered on the same day as ECT (care-level conflict).

Actionable requirementPrior authorization may be required for ECT services for specified commercial non-HMO members; providers must verify eligibility/benefits and obtain authorization per BCBSNM procedures.