CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Commercial Outpatient Benefit Prior Authorization Fully Insured Medical Surgical Procedure Code List

Lists outpatient procedure and service categories that require prior authorization for Blue Cross Blue Shield New Mexico commercial members and explains how providers request authorizations; applies to providers submitting claims for covered members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCommercial Outpatient Benefit Prior Authorization Fully Insured Medical Surgical Procedure Code List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionInitiate prior authorization requests online via Availity Authorizations tool (HIPAA-standard 278) or by phone using the number on the member's ID card.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multiplecare categories requiring prior authorization

Select outpatient listprocedure code list referenced

Carelon/AIMexternal vendor used

Phone / Availitymethods to initiate PA

Coverage and Prior Authorization Summary

Coverage summary

Coverage status and prior authorization requirements vary by member contract; presence of a code on the list does not guarantee coverage.

Coverage and prior authorization requirements depend on the member's specific benefit contract and product.

The presence of a procedure code on this outpatient prior authorization list does not necessarily indicate that the service is covered under a member's benefits.

Providers must consult the member benefit booklet or contact customer service to determine coverage for a specific medical service or supply.

Providers should verify preauthorization requirements and member eligibility through Availity prior to submitting services.

Outpatient Procedure Codes and List Details

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCommercial Outpatient Benefit Prior Authorization Fully Insured Medical Surgical Procedure Code List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionInitiate prior authorization requests online via Availity Authorizations tool (HIPAA-standard 278) or by phone using the number on the member's ID card.

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.

How Providers Request Prior Authorization

Prior Authorization

How to request prior authorization

Providers may initiate prior authorization (PA) requests online via Availity's Authorizations tool using the HIPAA-standard 278 transaction. Registered Availity users should refer to the Availity Authorizations User Guide for instructions. Alternatively, providers may call the prior authorization phone number shown on the member's ID card. For services managed by Carelon Medical Benefits Management (formerly AIM), providers may use the Carelon web portal (available 24/7) or call Carelon's toll-free number for submission and status inquiries.

Availity Authorizations tool (HIPAA 278) — registered Availity users; see Availity Authorizations User Guide
Phone — call the prior authorization number on the member's ID card
Carelon Medical Benefits Management portal: https://www.careloninsights.com/medical-benefits-management/specialty-care
Carelon phone (specialty care): 1-866-745-1789 (7 a.m. – 7 p.m. Mon–Fri except holidays)
For Carelon-handled services contact: 1-866-455-8415 or access Carelon website

Prior Authorization

Which services require prior authorization

Certain outpatient procedure categories require prior authorization through Carelon Medical Benefits Management for all Commercial members. Additional outpatient categories may require prior authorization for Commercial ASO members. The code lists are not exhaustive and may be updated; presence of a code does not guarantee coverage — verify member benefits and preauthorization requirements through Availity.

Categories requiring Carelon PA for all Commercial members: Molecular Genetic Lab Testing; Radiation Therapy / Radiation Oncology; Advanced Imaging / Radiology; Musculoskeletal – Pain; Musculoskeletal – Joint, Spine Surgery
Additional outpatient categories that may require PA for Commercial-ASO members: Molecular Genetic Lab Testing (Carelon); Radiation Therapy / Radiation Oncology (Carelon); Advanced Imaging / Radiology (Carelon); Musculoskeletal – Pain (Carelon); Musculoskeletal – Joint, Spine Surgery (Carelon); Sleep (AIM)
Select outpatient procedures that may require PA (see code list): Cardiology – Lipid Apheresis; ENT; Gastroenterology; Neurology; Outpatient Surgery (breast, deactivation of headache triggers, jaw); Pain Management; Sleep Studies; Wound Care
ALL services listed in Section 10.2 of the Provider Reference Manual, including ALL inpatient services, require authorization as specified
Specialty Pharmacy & Behavioral Health PA codes are provided on separate lists
Providers must check eligibility and benefits and verify preauthorization requirements through Availity

Vendor and Portal Definitions

Carelon / AIM

Carelon nameCarelon Medical Benefits Management (formerly AIM Specialty Health®).

Portal availabilityCarelon web portal available 24/7 for initiating cases, checking status, reviewing guidelines, and viewing authorizations/eligibility.

Carelon phoneToll-free: 1-866-745-1789 (7 a.m. to 7 p.m. Monday–Friday, except holidays).

Availity (authorization initiation)

Availity Authorizations toolRegistered Availity users may use Availity's Authorizations tool to initiate prior authorization requests (HIPAA-standard 278 transaction).

Phone alternativeProviders may also call the prior authorization number on the member's ID card to initiate requests.

User guidanceRefer to the Availity Authorizations User Guide for instructions on using the tool.