CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Prior Authorization Requirements List for Individual & Family Markets and Fully Insured Group Members

Defines BCBSNM's prior authorization and recommended clinical review processes for Individual & Family Markets and fully insured group members, listing services that require prior authorization and notification requirements for inpatient care.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrior Authorization Requirements List for Individual & Family Markets and Fully Insured Group Members

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionObtain eligibility and benefits first and contact BCBSNM Health Services at 800-325-8334 for prior authorization questions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

01/01/2024policy effective date

Pharmacy, inpatient, mental health, SUD, facilityservice categories

Initial 4 daysSUD exception

800-325-8334Health Services

Prior Authorization and Notification Criteria

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Prior authorization and notification criteria

Services and scenarios requiring prior authorization or notification per this document:

ALL of the following

ANY of the following
- Acute Care / Hospital
- Long Term Acute Care / Sub-acute
- Hospice Care
- Rehabilitation Facility
- Skilled Nursing Facility

ALL of the following

ANY of the following
- Inpatient
- Residential Treatment Center (RTC)

ALL of the following

Exception: initial 4 days of in-network SUD inpatient treatment do not require prior authorization

ALL of the following

Check the drug list/PA/Step Therapy program to determine if a specific drug requires prior authorization

ALL of the following

In-network unplanned or emergency inpatient hospital care requires notification of admission to the facility
Out-of-network unplanned or emergency inpatient admissions: notification is encouraged but not required

ALL of the following

Obtain eligibility and benefits first to confirm membership, verify coverage, and determine prior authorization requirements
Verification of eligibility and prior authorization is not a guarantee of payment; payment is determined at claim adjudication based on member eligibility and certificate terms on the date of service

Facility Admission Types and Special Coding Notes

Facility admission typesmixed

Acute Care / Hospital	Acute Care / Hospital
Long Term Acute Care / Sub-acute	Long Term Acute Care / Sub-acute
Hospice Care	Hospice Care
Rehabilitation Facility	Rehabilitation Facility
Skilled Nursing Facility	Skilled Nursing Facility

SUD inpatient initial coverage exception

Exception detailInitial 4 days for in-network SUD inpatient treatment do not require prior authorization

Applies toPlanned elective substance use disorder inpatient hospital care (inpatient rehab)

Scope limitationException applies only to in-network admissions; prior authorization still required for planned elective SUD inpatient care beyond the initial 4 days

Prior Authorization, Pharmacy, and Administrative Actions for Providers

Prior Authorization

Prior authorization overview and contact

Prior Authorization is required by BCBSNM for certain services to determine medical necessity or whether care is experimental, investigational, or unproven based on MCG Criteria, Medical Policy, and member benefits. Obtain eligibility and benefits first to confirm membership and determine whether prior authorization is required. For questions or to request prior authorization, contact the BCBSNM Health Services Department at 800-325-8334.

Prior authorization required to assess Medical Necessity or Experimental/Investigational status
Verify eligibility and benefits before requesting prior authorization
BCBSNM Health Services Department: 800-325-8334

Prior Authorization

Facility and behavioral health prior authorization and notification rules

Prior authorization is required for all elective inpatient facility admissions (acute care/hospital, long-term acute care/sub-acute, hospice, rehabilitation facility, skilled nursing facility), for elective mental health inpatient and RTC admissions, and for planned elective substance use disorder inpatient care (with an exception noted below). Notification of admission to the facility is required for in-network unplanned or emergency inpatient hospital care; notification is encouraged but not required for out-of-network unplanned or emergency inpatient admissions.

Elective inpatient facility admissions require prior authorization
Mental health inpatient and Residential Treatment Center (RTC) admissions require prior authorization for elective care
Planned elective SUD inpatient care requires prior authorization (see SUD exception)
In-network unplanned or emergency inpatient hospital care requires notification to the facility
Out-of-network unplanned or emergency inpatient admissions: notification encouraged but not required

Prior Authorization

Pharmacy prior authorization (Prime)

Some medications require prior authorization under BCBSNM's Prime pharmacy benefits. Check the drug list guide and the Prior Authorization/Step Therapy Program information to determine whether a specific drug requires prior authorization under pharmacy benefits.

Review the drug list guide to see if a medication requires prior authorization
Consult the Prior Authorization/Step Therapy Program details for Fully Insured members

Documentation Required

Authorization is not a guarantee of payment

Verification of eligibility and prior authorization is not a guarantee of payment; final payment determination occurs at claim adjudication based on the member's eligibility and the terms of the member's certificate of coverage effective on the date of service.

Preauthorization or eligibility verification does not ensure benefits will be paid
Benefits are decided when a claim is received and adjudicated against the member's coverage

Key Terms

Prior authorization — definition

DefinitionA preservice review required by BCBSNM to determine in advance whether services are medically necessary or are Experimental, Investigational and/or Unproven, based on MCG Criteria, Medical Policy, and member benefits.

When usedRequired for specific services listed in the policy; obtain eligibility and benefits first to confirm whether prior authorization is needed.

PurposeTo assess benefits and medical necessity before services are provided.

Recommended clinical review — definition

DefinitionA preservice review option that is elective for services that do not require prior authorization; similar to prior authorization but not mandatory.

Primary difference from prior authorizationRecommended clinical review is voluntary; prior authorization is required for certain services.

Use caseRequested when providers seek an advisory review for services that are not on the required prior authorization list.