Preauthorization Requirements (Carelon/AIM) — BCBSNM
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Defines prior authorization, notification, and medical necessity requirements for Blue Cross Blue Shield New Mexico members (Medicaid and commercial where specified), including services requiring authorization and procedures for using Carelon (AIM) beginning 01/01/2026.
No material clinical or coverage changes in this revision.
Preauthorization and Notification Criteria
Preauthorization and notification criteria
Preauthorization and notification requirements vary by service; many categories reference the comprehensive preauthorization grid for code-level rules.
Facility admissions
- Planned (elective) inpatient hospital care (surgical, non-surgical, behavioral health and/or substance abuse) requires prior authorization BEFORE admission.
- Unplanned (emergency) inpatient hospital care requires notification to the plan WITHIN one business day of admission.
- All admissions to a skilled nursing facility (SNF), long term acute care hospital (LTACH), rehabilitation facility, and residential treatment programs require prior authorization.
Behavioral health and substance use services
- Inpatient psychiatric services, inpatient substance abuse services, and many residential and specialty behavioral services require prior authorization; see behavioral section details and the preauthorization grid.
Partial hospitalization
- Prior authorization is required for episodes of partial hospitalization that exceed 45 days.
Diagnostic imaging and procedures
- PET, MRA, MRI, CT scans, laboratory, X-ray, EKGs, and other advanced imaging/diagnostic tests: refer to the comprehensive preauthorization grid/PDF for authorization requirements and code-level determinations.
Specific clinical services
- Chemotherapy and radiation therapy require prior authorization; consult the preauthorization grid for details.
- Dialysis services require prior authorization; special rules apply for out-of-network/out-of-state and for CPT 90999 and chronic dialysis frequencies.
- Many DME, home health, injections, minor surgeries, special rehabilitation services (PT/OT/ST), transplants and pre-transplant evaluations require prior authorization per the preauthorization grid.
Network participation
- Out-of-network providers must obtain prior authorization for all services except emergency services, emergency ambulance, stabilization, and IHS services.
Code-level determinations
- Providers must consult the BCBSNM AIM webpage and the comprehensive preauthorization grid/PDF for the definitive list of CPT/HCPCS procedure codes that require review and for service-specific rules.
Codes, Thresholds, and Coding Rules
| Comprehensive preauthorization grid lists procedure codes (CPT/HCPCS) that require review; see BCBSNM AIM PDF. |
What Providers Must Do — Authorization, Notification, and Review
Prior Authorization: How to request and check
Use the Carelon (AIM) web portal or call Carelon to initiate cases, check status, and view authorizations. Portal: https://guidelines.carelonmedicalbenefitsmanagement.com/ or Call Carelon Contact Center at 1-800-859-5299 (Monday–Friday 6 a.m.–6 p.m. CT; weekends/holidays 9 a.m.–noon CT). For Medicaid medical/surgical/behavioral health prior authorization, call 1-866-689-1523 (Monday–Friday 8 a.m.–8 p.m. local time).
- Carelon web portal: https://guidelines.carelonmedicalbenefitsmanagement.com/
- Carelon Contact Center: 1-800-859-5299
- Medicaid prior auth line: 1-866-689-1523
Network participation: prior authorization rule
Out-of-network providers must obtain prior authorization for all services except emergency services, emergency ambulance services, stabilization, and services provided by I.H.S. This includes network exceptions such as Out of Plan or Out of Network due to network adequacy.
Inpatient and post-acute authorization
Prior authorization is required for all planned (elective) inpatient hospital care and for admissions to skilled nursing facilities, long-term acute care hospitals (LTACHs), rehabilitation facilities, and residential treatment programs. Elective admissions must have prior authorization before the admission occurs.
- Planned (elective) inpatient hospital care — prior authorization required before admission
- Admissions to SNF, LTACH, rehabilitation facilities, and residential treatment programs — prior authorization required
Emergency/unplanned admission notification
For emergency or unplanned inpatient admissions, providers must notify the plan within one business day of admission.
- Notify within one business day of an emergency or unplanned inpatient admission
Medical necessity and retrospective review
All services must meet the plan’s medical necessity criteria regardless of whether prior authorization was obtained. Services are subject to retrospective review and possible recoupment if they do not meet medical necessity, in accordance with State and Federal rules and regulations. Claims without required benefit preauthorization numbers may be denied; independently contracted providers may not bill members for services denied as not medically necessary.
- Medical necessity required for all services
- Services subject to retrospective review and potential recoupment
- Claims without required preauthorization numbers may be denied
Refer to preauthorization grid for codes
Refer to the comprehensive preauthorization grid/PDF on the BCBSNM AIM webpage for the full list of CPT/HCPCS procedure codes that require review or preauthorization. The PDF is searchable and bookmarkable for ease of use.
- Comprehensive preauthorization grid/PDF available on BCBSNM AIM webpage
- Searchable/bookmarkable PDF lists specific CPT/HCPCS codes requiring preauthorization
Key Definitions
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