ModifiedBlue Cross Blue Shield - New MexicoPolicy N/A

Commercial Outpatient Benefit Prior Authorization ASO Medical Surgical Procedure Code List

A payer-managed list of outpatient medical and surgical procedure codes that may require prior authorization for ASO commercial members; affects providers submitting authorization requests to Blue Cross Blue Shield - New Mexico and Carelon Medical Benefits Management.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCommercial Outpatient Benefit Prior Authorization ASO Medical Surgical Procedure Code List

Policy CodePolicy N/A

Change TypeAdded codes effective 01/01/2024vendor mapping updates

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionProviders must initiate prior authorization for listed outpatient categories through Carelon via the Carelon web portal or by phone.

SourceLink

POLICY UPDATE CHANGES

Multiple CPT/HCPCS codes (including many musculoskeletal and advanced imaging codes and new molecular genetics and oncology J- and U-codes) were added effective 01/01/2024 and are managed by Carelon.

01/01/2024effective date for many added codes

dozensprocedure codes listed (musculoskeletal, advanced imaging, molecular testing, oncology)

2ways to initiate prior authorization (web portal or phone)

200+molecular/genetic and U-codes listed in this window

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3vendor/third-party entities named

Prior Authorization Coverage Criteria and Code Listings

Authorization and coverage stance

Prior authorization requirement and verification instructions

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

Providers must verify member-specific eligibility and benefits and confirm preauthorization requirements via Availity, the member benefit booklet, or the Carelon/BCBSNM contact points provided (Carelon web portal or phone).

Presence of a code on this list does not necessarily indicate coverage under the member's benefits contract; final coverage is determined by member benefit contract and claim adjudication.

Prior authorization listing (excerpt)

Codes listed under Advanced Imaging/Radiology are part of the prior authorization code list and associated with Carelon as the reviewer; specific coverage determinations or clinical criteria are not included in this excerpt.

Procedure codes mapped to Advanced Imaging / Radiology in this excerpt require prior authorization and are routed to Carelon for review.

Some entries include administrative 'Add Effective' annotations (e.g., Add Effective 07/01/2023) indicating the effective date for that code mapping.

Example codes shown in this excerpt include 73218, 73700, 74170, 78832, 0042T, 0633T, 0649T, and C8900 (all assigned to Carelon in the list).

Coverage stance (partial)

This excerpt maps procedure codes to service categories and assigns an authorization manager; it does not include clinical coverage criteria in these chunks.

Each listed procedure code is associated with a service category (e.g., Advanced Imaging/Radiology, Ear/Nose/Throat, Cardiology) and identifies the authorization manager (Carelon or BCBSNM) for that code.

Assignments shown are administrative routing only; no clinical coverage criteria or medical-necessity conditions are provided in this excerpt.

Coverage stance for listed molecular genetic CPT codes

This segment is a code list indicating that listed molecular genetic tests are subject to prior authorization review by Carelon; some codes have effective-date notes.

Listed molecular genetic CPT codes (examples: 81233–81246 range entries, 81415, 81418, 81442, 81460, etc.) are designated as 'Molecular Genetic Lab Testing' and routed to Carelon for prior authorization review.

Some molecular genetic entries include 'Add Effective' annotations (e.g., Add Effective 07/01/2023) that indicate the administrative effective date for the code being added to the list.

Coverage stance for listed genetic tests

This segment enumerates molecular genetic and related U-codes that require prior authorization and assigns Carelon as the reviewer; some codes include administrative notes about effective or terminated status.

Proprietary (U-) codes and higher-level molecular genetic/genomic CPT codes listed (examples: 81442, 81460, 0244U, 0278U, 0285U, etc.) are categorized as Molecular Genetic Lab Testing and are routed to Carelon for prior authorization.

Entries include some administrative annotations such as 'Add Effective 07/01/2023' for select codes; these are administrative effective-date notes, not clinical criteria.

Listing / informational

This segment is a listing of procedure codes and administrative routing; it does not itself state clinical coverage criteria.

Procedure codes are listed with category/group and the designated authorization handler (commonly Carelon); some codes in this window include 'Add Effective' notes indicating administrative effective dates.

The list functions as an administrative routing table—identifying which codes may require authorization and which vendor (Carelon or BCBSNM) handles the request—without providing clinical coverage rules in these chunks.

Prior authorization and coding notes

Codes listed are subject to prior authorization through Carelon; select entries include explicit PA requirement or code status notes.

Certain procedure codes are explicitly noted as requiring prior authorization (example: 27412 is marked 'Prior Authorization required' and routed to Carelon).

Operational coding updates are noted where applicable (example: temporary code 0163T is indicated as termed and replaced by permanent CPT 22860).

Listed procedure codes and reviewer assignment

Codes and reviewer assignments (no clinical criteria included in these chunks).

Procedure codes are listed with their clinical/administrative category and the assigned reviewer organization (examples: 64483 = Musculoskeletal Pain → Carelon; 61863 = Neurology → BCBSNM; 77432 = Radiation Therapy → Carelon).

These entries represent administrative reviewer assignment for prior authorization handling and do not contain clinical medical-necessity criteria in the listed chunks.

Administrative coverage notes and vendor assignments

Administrative coverage stance and payment disclaimer

Carelon Medical Benefits Management is the contracted utilization management vendor for numerous listed codes; Availity is used for electronic information exchange and member eligibility/preauthorization checks.

Prior authorization or pre-notification is not a guarantee of payment; final benefits and payment are determined upon claim receipt and according to the member's benefit contract.

Blue Cross and Blue Shield of New Mexico makes no endorsement or warranty regarding products or services provided by third-party vendors such as Availity or Carelon.

Procedure Codes, Statuses, and Effective Dates

Examples of added or listed codes (musculoskeletal, oncology, molecular, imaging)mixedCovered

J9345	Inj, retifanlimab-dlwr, 1 mg
J9350	Inj Mosunetuzumab-Axgb 1 mg
0364U	Onc Hl Neo Gen Seq Alys Alg
23700	Mnpj Anes Sho Jt Fixj Aprats
29805	Sho Arthrs Dx +- Synovial Bx
70450	CT Head/Brain w/o Dye

Advanced Imaging / Radiology codes in this excerptCPT | HCPCS | mixedCovered

73218	MRI upper extremity without dye (mapped to Advanced Imaging/Radiology)
73700	CT lower extremity without dye (mapped to Advanced Imaging/Radiology)
74170	CT abdomen without & with dye (mapped to Advanced Imaging/Radiology)
78832	Radiopharmaceutical localization with SPECT/CT (mapped to Advanced Imaging/Radiology)
0042T	CT perfusion with contrast CBF (advanced imaging)
0633T	CT breast with 3D unilateral, contrast negative (advanced imaging)
0649T	Quantitative MR tissue with MRI (advanced imaging) — noted with Add Effective 07/01/2023
C8900	Gallium locametz 1 millicuri (mapped to advanced imaging/radiology) — Add Effective 07/01/2023

Imaging / Radiology codes (partial)CPT

78832	Lung perfusion differential / Rp Loclzj Tum SPECT w/CT (listed under Imaging/Radiology)
0042T	Advanced imaging / CT perfusion w/contrast CBF (listed)
0633T-0638T	Advanced imaging CT breast 3D variations (listed)

ENT and implant codes (partial)mixed

30120-31299	Ear, nose, and throat procedure codes (nasal and sinus surgeries listed)
69714-69930	ENT implant/ cochlear device procedures
L8614-L8693	Cochlear device supply/replacement HCPCS codes

Molecular genetic lab testing codes (partial)CPT

81120-81248

Molecular genetic laboratory testing codes (many individual gene tests listed)

selected molecular genetic CPT codesCPT

81233	Btk Gene Common Variants / molecular genetic lab testing
81234	Dmpk Gene Detection Abnormal Allele / molecular genetic lab testing
81235	Egfr Gene Common Variants / molecular genetic lab testing
81415	Exome Sequence Analysis / molecular genetic lab testing
81418	Rx Metab Gene Sequence Analysis Panel 6 (note: 'Add Effective 07/01/2023')

Molecular genetic / genomic CPT and proprietary U-codesmixed

81442	Molecular Genetic Lab Testing — Noonan Spectrum Disorders
81460	Molecular Genetic Lab Testing — Whole Mitochondrial Genome
0153U	Onc Breast Mrna 101 Genes
0244U	Trgt Gen Seq Alys Pnl 55-74 = Onc Solid Orgn Dna 257 Genes

Molecular genetic / U-codes and selected HCPCSmixed

0278U	Molecular Genetic Lab Testing; Hem Gen Thrombosis 14 Genes
0332U	Onc Pan Tum Gen Prflg 8 Dna (note: Add Effective 07/01/2023 appears for nearby codes in this range)
G9143	Warfarin Response Genetic Test

Musculoskeletal, joint and spine CPT codesCPT

20930	Sp Bone Algrft Morsel Add-On
22206	Incision Spine 3 Column Thoracic
22840	Insert Spine Fixation Device
27130	Total Hip Arthroplasty

Musculoskeletal joint, spine surgery and pain procedure codesmixedCovered

23440	Remove/Transplant Tendon (shoulder-related)
27130	Total Hip Arthroplasty
27412	Autologous chondrocyte implant knee (PA required)
63012	Remove Lamina/Facets Lumbar
63650	Implant Neuroelectrodes (spinal cord stimulation)
64483	Injection/Procedure series for epidural/paravertebral (musculoskeletal pain)
0095T	Removal artificial disc additional cervical
0163T	Total disc arthroplasty (code termed; replaced by 22860)

examples of codes in this chunkCPTCovered

64483	Procedure code listed under Musculoskeletal Pain with reviewer Carelon
61850	Implant Neuroelectrodes — assigned to Neurology category and reviewer BCBSNM
77432	Stereotactic Radiation Treatment — Radiation Therapy category and reviewer Carelon

selected HCPCS/NDC examplesHCPCSCovered

A0430	Fixed Wing Air Transport — Non-Emergent Air Ambulance
A4290	Sacral Nerve Stim Test Lead

Radiation therapy / radiopharmaceutical codesHCPCS

A9543	Radiopharmaceutical - vendor entries
A9590	Iodine I-131 Iobenguane
A9600	Sr89 Strontium
A9604	Sm 153 Lexidronam
A9606	Radium Ra223 Dichloride
A9607	Lutetium Lu 177 Vipivotide
G0339	Robot Lin-Radsurg Com / Robotic radiosurgery

Sleep diagnostics and CPAP/DME codesCPT/HCPCS

64582	Implantable hypoglossal nerve stimulator procedures
95782	Polysomnography (pediatric) with >4 parameters
95800	Polysomnography unattended (home) types and variants
E0601	Continuous airway pressure device
G0398	Home sleep test / type 2 portable

Transplant evaluation and procedure codesCPT/mixedCovered

32851	Lung transplant (single)
33945	Heart transplantation
38206	Harvest autologous stem cells
38230	Bone marrow harvest (allogeneic)
0584T	Perq islet cell transplant (Category III)

Codes with explicit effective date — examples (07/01/2023)

Example effective-date annotation0649T — entry shows 'Add Effective 07/01/2023' for this code

Advanced imaging exampleC8900 — listed with 'Add Effective 07/01/2023' annotation

Additional imaging exampleC8914 — listed with 'Add Effective 07/01/2023' annotation

What Providers Must Do

Prior Authorization

How to initiate prior authorization

Prior authorization is required for services in the listed categories and for specific procedure codes. For services managed by Carelon Medical Benefits Management (Carelon), providers must initiate prior authorization with Carelon. Use the Carelon web portal (available 24/7) at https://Carelonspecialtyhealth.com or call Carelon at 1-866-455-8415. For services handled directly by Blue Cross Blue Shield of New Mexico (BCBSNM), providers may initiate authorization by using Availity's Authorizations tool (HIPAA-standard 278 transaction) if registered, or by calling the prior authorization number on the member's ID card or BCBSNM customer service at 1-866-745-1789 (7 a.m. to 7 p.m. Monday–Friday, except holidays). Always verify member eligibility, benefits and preauthorization requirements via Availity before submitting requests.

Carelon web portal (preferred): https://Carelonspecialtyhealth.com
Carelon phone: 1-866-455-8415
BCBSNM phone (general prior auth/help): 1-866-745-1789 (7 a.m.–7 p.m. M–F)
Availity Authorizations tool (registered users) / HIPAA 278 transaction

Note

Verify member benefits & coverage

Terms and Vendor Definitions

Administrative Services Only (ASO) commercial members — definition

DefinitionAdministrative Services Only (ASO) commercial members — members whose employers purchase administrative services only from BCBSNM (listed as the affected population for prior authorization requirements).

ContextThis code list applies to ASO members and notes that not all requirements apply to every product; providers must check eligibility.

Initiation methodsProviders may initiate prior authorization via the Carelon web portal or by phone (Carelon and BCBSNM contact details provided).

External manager designated to handle prior authorization — Carelon

Designated external managerCarelon Medical Benefits Management — external utilization management organization designated to handle prior authorization for specified outpatient care categories (e.g., molecular genetic testing, radiation therapy, advanced imaging, musculoskeletal).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCommercial Outpatient Benefit Prior Authorization ASO Medical Surgical Procedure Code List

Policy CodePolicy N/A

Change TypeAdded codes effective 01/01/2024vendor mapping updates

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionProviders must initiate prior authorization for listed outpatient categories through Carelon via the Carelon web portal or by phone.

SourceLink

On This Page

Codes with effective/termination notes — examples

Add Effective exampleMultiple molecular/genetic entries (e.g., 81449, 81451, 81456) include 'Add Effective 07/01/2023' annotations

Code termed exampleSome U-codes and temporary codes in molecular ranges include termination or add-effective notes affecting authorization handling

Late-2023 addsSelect proprietary U-codes (e.g., nearby entries) show 'Add Effective' administrative notes for 2023

Code termination and replacement

Terminated and replaced code0163T — indicated as termed and replaced by 22860 (noted in list)

Replacement CPT22860 — cited as the permanent CPT code replacing 0163T

ContextReplacement noted in musculoskeletal joint/spine surgery code segment relevant to authorization

Retired code effective date example

Retired code example79005 — entry shows 'Retire effective 10/01/2023'

Service category79005 mapped to Radiation Therapy/Radiation Oncology in the list

Reviewer assignmentEntry lists Carelon as reviewer for radiation therapy codes (79005 included)

Added code effective date example

Added code exampleA9607 — listed with 'Add effective 01/01/2023' annotation

Service categoryA9607 mapped to Radiation Therapy/Radiation Oncology

Reviewer assignmentCarelon is listed as the utilization management vendor for A9607

Prior authorization note (payment & verification)

Payment disclaimerPrior authorization or pre-notification is not a guarantee of payment; benefits adjudicated when the claim is received and in accordance with member coverage.

Verify benefitsProviders must verify member-specific eligibility and benefits and confirm preauthorization requirements via Availity or member benefit booklet.

Initiating PAPrior authorization requests handled by Carelon or BCBSNM may be initiated via the Carelon web portal or by phone (numbers provided in list).

Providers must verify member eligibility and benefits and confirm whether prior authorization is required for the specific product/network (PPO, Blue Preferred EPO, Blue Preferred Plus, HMO) before delivering services. Use Availity or the member benefit booklet and contact customer service as needed. The presence of a code on this list does not guarantee coverage—benefits vary by contract.

Verify eligibility and benefits via Availity®
Consult member benefit booklet or contact BCBSNM customer service

Prior Authorization

Prior authorization required for listed advanced imaging/radiology codes

A large set of advanced imaging/radiology CPT, HCPCS and temporary codes on the code list require prior authorization and are assigned to Carelon for review. Providers must route prior authorization requests for these advanced imaging services to Carelon using the methods above.

Advanced imaging/radiology codes (examples in list) are assigned to Carelon for prior authorization review
Some advanced imaging codes on the list include ‘Add Effective’ annotations — see effective-date callout below

Note

Code-to-authorization-entity mapping (partial)

The code list shows which organization handles prior authorization for each listed code. Many codes are assigned to Carelon; some outpatient procedures and select services are assigned to BCBSNM. Providers should follow the mapped authorization entity shown for each code when initiating authorization.

Code-to-authorization-entity mapping is provided in the code list (Carelon or BCBSNM)
If a code row shows Carelon = Carelon, route the PA to Carelon; if it shows Carelon = BCBSNM or BCBSNM = BCBSNM, route to BCBSNM

Note

Effective-date annotations

Some codes in the list include effective-date annotations (for example, 'Add Effective 07/01/2023' or 'Add effective 01/01/2023'). These indicate the date the code was added to the prior-authorization list and should be used to determine when the PA requirement applies.

Examples: 0649T — Add Effective 07/01/2023
C8900–C8934 series — Add Effective 07/01/2023 entries
Select molecular genetic panel codes (e.g., 81449, 81451, 81456) — some show Add Effective 07/01/2023
A9607 — Add effective 01/01/2023

Prior Authorization

Prior authorization requirement — molecular genetic testing codes

Molecular genetic testing codes listed (CPT and proprietary U- and S- codes) require prior authorization and are routed to Carelon for review. Providers must obtain prior authorization from Carelon before scheduling or performing molecular genetic tests that appear on the list.

Molecular genetic lab testing codes (e.g., 81233–81246 series, 81442–81471 series, 81479, 81493, 81504, 81518–81523, 0278U–0291U, etc.) are subject to Carelon review
Many proprietary and panel codes (0278U, 0285U, 0286U, etc.) are assigned to Carelon

Prior Authorization

Prior authorization routing

Providers should route prior authorization requests to the entity assigned in the code list: most molecular genetic, advanced imaging, radiation therapy, musculoskeletal pain and sleep/DME codes are assigned to Carelon; select outpatient procedures and transplant/transplant-evaluation codes are assigned to BCBSNM. Verify the assigned reviewer per code in the list.

Carelon handles molecular genetic testing, radiation therapy, advanced imaging, musculoskeletal pain, sleep services and DME listed on the code list
BCBSNM handles many transplant-related procedure codes and select outpatient procedures (codes in Transplant Evaluations and Transplants section)

Note

Prior authorization and code status notes

Some codes include additional status notes — for example, entries indicating 'Prior Authorization required' or notes that a code was replaced/terminated. Providers must check the code row notes to confirm whether PA is required and whether the code has been replaced by another code.

Example: 27412 — entry includes 'Prior Authorization required'
Example: certain spine procedure codes indicate 'code is now replaced by 22860' — verify current code and PA requirement

Note

Reviewer assignments for listed codes

Reviewer assignments are shown next to each code in the list. Use the assignment to determine which organization will process the authorization — e.g., 'Carelon' indicates Carelon Medical Benefits Management will review; 'BCBSNM' indicates BCBS of New Mexico will review the request.

Codes annotated with 'Carelon' — submit to Carelon
Codes annotated with 'BCBSNM' — submit to BCBSNM

Prior Authorization

Radiation therapy prior-authorization vendor assignments

Radiation therapy and radiation oncology procedure codes listed (G-series, G6001–G6017, Q3001, S8030, A9590–A9607, etc.) are assigned to Carelon for prior authorization review. Providers must route radiation therapy prior authorization requests to Carelon.

Examples of Radiation Therapy codes assigned to Carelon: G0339, G0340, G0341 series; G6001–G6017; Q3001; A9590, A9600, A9604, A9606, A9607 (A9607 has Add effective 01/01/2023)

Prior Authorization

Sleep services and DME prior-authorization vendor assignments

Sleep diagnostics, home sleep tests, PAP devices and many DME/supplies used for sleep are assigned to Carelon for prior authorization. This includes sleep procedure codes (64582–64584), polysomnography codes (95xxx), home sleep test codes (G0398–G0400), PAP/DME HCPCS codes (A46xx, A70xx, A70xx series, E04xx, E05xx, E06xx) and related accessory codes.

Sleep procedure and device codes (e.g., 64582–64584, 95782, 95800–95811) — Carelon
Home sleep test codes (G0398, G0399, G0400) — Carelon
DME/supplies for sleep (A4604, A7027–A7046, C1767, E0470–E0486, E0561–E0562, E0601, etc.) — Carelon

Denial Risk

Administrative vendor and payment disclaimer

Carelon is an independent contractor providing utilization management services to BCBSNM and Availity provides electronic information exchange services. Neither Availity nor Carelon are endorsed by BCBSNM; prior authorization or pre-notification is not a guarantee of payment. Final payment depends on member eligibility and the terms of the member's certificate of coverage when services are rendered.

Availity is an administrative vendor providing electronic exchange services to BCBSNM
Carelon Medical Benefits Management is an independent contractor providing utilization management services
Prior authorization is not a guarantee of payment — benefits are determined at claim adjudication based on member eligibility and the member certificate of coverage

Contact methodsCarelon cases may be initiated via Carelon web portal (URL in document) or by phone at 1-866-455-8415; Carelon is contracted with BCBSNM to provide utilization management services.

ScopeCarelon is listed as reviewer/authorization handler next to numerous CPT/HCPCS entries across multiple service categories in the list.

Carelon — reviewer/vendor associated with prior authorization for listed procedure codes

Named reviewer/vendorCarelon — named as the review/vendor associated with many listed procedure codes (e.g., 73218, 78832, 81233) in the code list.

Service categoriesCarelon is assigned for categories including Advanced Imaging/Radiology and Molecular Genetic Lab Testing as shown in multiple code segments.

Code examplesExamples showing Carelon as reviewer: 73218 (Advanced Imaging), 78832 (Imaging/Radiology), 81233 (Molecular Genetic Lab Testing).

Annotation: Add Effective 07/01/2023

Effective 07/01/2023 annotation'Add Effective 07/01/2023' appears next to several codes in the list indicating the code entry was added effective July 1, 2023.

Examples0649T and multiple C89xx/C89xx-series entries show this 'Add Effective 07/01/2023' annotation in the Advanced Imaging/Radiology segment.

ImpactThese annotations indicate the date the code mapping and authorization assignment take effect for prior authorization handling.

Authorization entity mapping

Authorization entity mapping'Carelon' or 'BCBSNM' noted next to a code indicates the designated authorization manager responsible for that procedure code in the list.

Examples78832 = Carelon; 36516 = BCBSNM; 64483 = Carelon; 61863 = BCBSNM — illustrating code-to-entity mappings.

Operational noteProvider should route PA requests to the entity shown next to the specific code for authorization processing.

Molecular genetic lab testing codes — code ranges

Code range example81120–81248 — identified in the document as molecular genetic laboratory testing codes (individual gene analyses or variant panels)

Reviewer assignmentEntries in this range consistently list Carelon as the reviewer/authorization handler.

Service labelThese codes are categorized under 'Molecular Genetic Lab Testing' in the list.

Carelon — utilization management organization for listed codes

Carelon listed as UM organizationCarelon — listed repeatedly as the utilization management organization associated with the molecular genetic and other listed procedure codes.

Examples81233, 81234, 81442, 81460 entries show 'Carelon' in the reviewer/handler field.

ImplicationPrior authorization requests for these codes should be submitted to Carelon per the list assignments.

Molecular Genetic Lab Testing — service category applied to CPT codes

Service category labelMolecular Genetic Lab Testing — applied as the service category for numerous CPT entries (examples: 81442, 81460, 81465)

ReviewerCarelon assigned as reviewer for these molecular genetic entries

Add Effective notesSome molecular genetic entries include 'Add Effective' administrative notes indicating effective dates (e.g., 81449 'Add Effective 07/01/2023').

Designated utilization management reviewer/administrator — Carelon

Designated reviewer for testsCarelon — consistently listed as the designated utilization management reviewer/administrator for the molecular genetic tests shown in the list.

Examples81189, 81200, 0278U entries show 'Carelon' noted as reviewer/handler.

Submission implicationProviders should direct prior authorization requests for these tests to Carelon per the list assignment.

Authorization routing vendor indicated for listed procedure codes

Authorization routing vendor indicatedCarelon — listed next to multiple procedure codes indicating Carelon is the authorization routing/vendor for those entries.

Examples0278U, 20930 and many other CPT entries show Carelon as the routing/vendor in the list.

ActionSubmit PA requests to Carelon when that is the entity listed for the specific code.

Administrative note indicating code addition effective on a specified date

Administrative 'Add Effective' note'Add Effective' — administrative note indicating a code or mapping was added to the list effective on a specified date (e.g., 'Add Effective 07/01/2023' or 'Add Effective 10/01/2023').

Examples0649T, 81449, 0350U entries include 'Add Effective' annotations in the document.

PurposeUsed to communicate when a code entry or assignment becomes effective for prior authorization handling.

Designated prior authorization reviewer/manager — Carelon

Designated prior authorization reviewerCarelon — listed as the designated prior authorization reviewer/manager for many of the procedure codes in the list (musculoskeletal, joint/spine surgery examples included).

Examples23440, 27412, 64483 entries show Carelon as the reviewer for these surgical/pain procedure codes.

Provider actionRoute PA requests to Carelon for codes that list Carelon as the reviewer in the document.

Temporary (T) code terminated and replaced by permanent CPT — example

Temporary (T) code termination example0163T — documented as terminated and replaced by permanent CPT 22860 in the list ('code is now replaced by 22860').

Replacement code22860 — cited as the code that replaces the terminated temporary code (0163T).

Segment contextNoted in the musculoskeletal joint/spine surgery segment relevant to authorization and coding updates.

Carelon / BCBSNM — organizations assigned to handle prior authorization

Assigned organizationsCarelon / BCBSNM — organizations assigned to handle prior authorization determinations for listed procedure codes (specified per-code in the list).

Examples64483 = Carelon; 318xx/30120-type ENT entries = BCBSNM; mapping varies by code as shown in the document.

Operational noteProviders should check the entity listed next to each code to determine where to submit the authorization request.

Clinical/administrative grouping for codes

Groupings exampleCodes are grouped by clinical/administrative categories such as Musculoskeletal Pain, Neurology, Radiation Therapy — used to organize prior authorization assignments.

Examples64483 categorized as Musculoskeletal Pain; 61850/61863 examples assigned to Neurology; 77432 assigned to Radiation Therapy.

PurposeCategory labels help route prior authorization requests and indicate the clinical area related to the code.

Carelon Medical Benefits Management — contracted utilization management vendor

Contracted UM vendor for BCBSNMCarelon Medical Benefits Management — contracted utilization management vendor for BCBSNM for members with coverage through BCBSNM, responsible for prior authorization handling for many listed codes.

Contact infoCarelon web portal and phone number provided in the document for submitting prior authorization requests (web URL and 1-866-455-8415).

ScopeCarelon is referenced across multiple service categories in the list as the assigned reviewer/authorization manager.

Availity — electronic information exchange & administrative services

Availity roleAvaility — separate company operating a health information network providing electronic information exchange services and administrative services to BCBSNM (used for verifying eligibility and submitting authorizations).

Provider actionRegistered Availity users may use Availity's Authorizations tool (HIPAA-standard 278 transaction) as one way to initiate prior authorization requests.

DisclaimerAvaility is independent and provides administrative services; presence of a code on the list does not guarantee coverage.