CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Summary of Services Requiring Prior Authorization for Medicaid

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicySummary of Services Requiring Prior Authorization for Medicaid

Policy CodePolicy N/A

Change TypeNo material change reported

Effective Date

Next Review Date

Key ActionObtain prior authorization for elective inpatient admissions; notify the plan within one business day for emergencies; beginning 2026-01-01, use Carelon (AIM) for radiology PA for members over 18; document medical necessity before requesting preauthorization; consult the comprehensive preauthorization grid for category-specific authorizations.

SourceLink

POLICY UPDATE CHANGES

No material changes — brief indicates no material clinical/coverage changes.

manyService categories listed

1/1/2026Radiology Carelon effective date noted

3Pregnancy ultrasound allowance

Coverage Summary

Summary of services requiring prior authorization for Blue Cross Blue Shield New Mexico Medicaid members across medical, surgical, radiology, behavioral health and other service categories; includes network, notification, medical necessity, inpatient admission, and category-specific preauthorization requirements. For specific procedure codes that require review, consult the comprehensive preauthorization grid (PDF). Note: Radiology prior authorization for adults (members over 18) transitions to Carelon (AIM) effective 2026-01-01; use the Carelon web portal or contact center for adult radiology preauthorization requests.

Document-level numeric thresholds

Pregnancy-related ultrasound allowanceMembers permitted to have 3 ultrasounds without preauthorization

Partial Hospitalization prior authorization thresholdPrior authorization required only for episodes of care beyond 45 days

Respite care annual limit before prior authorizationServices beyond an annual limit of 30 days or 720 hours require prior authorization

Radiology prior authorization transition (adults)Radiology preauthorization for members over 18 managed via Carelon (AIM) effective 2026-01-01

General Prior Authorization & Medical Necessity Criteria

General Prior Authorization and Notification Requirements

Prior authorization or notification requirements applying to Medicaid members:

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Documentation / Eligibility Conditions

Documentation / eligibility conditions:

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Category-specific Preauthorization Criteria

Category-specific Preauthorization Summary (by service category)

Coverage / preauthorization requirements by service category as listed in the policy:

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Radiology Prior Authorization via Carelon (AIM)

Specific operational requirements for radiology prior authorization for members over 18:

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Codes and Coding Notes

Codes requiring review - see comprehensive preauthorization gridmixed

No codes listed

Dialysis special note codeCPT

90999

Unlisted dialysis procedure (noted for out-of-network/out-of-state chronic dialysis >3 times/week)

ABA specific CPT/HCPCS codes requiring prior authorizationmixedCovered

97153	Adaptive Behavior Treatment by Protocol (PA required)
0373T	Adaptive Behavior Treatment with Protocol Modification (Specialty Care) (PA required)

The comprehensive preauthorization grid (PDF/BCBSNM portal) contains the full procedure-code list that requires review; the PDF supports bookmarking and searching for codes. Radiology-specific prior authorization rules for adults are handled via Carelon (AIM) effective 2026-01-01.

Provider Actions & Operational Requirements

Prior Authorization

Obtain prior authorization for elective inpatient admissions

Elective inpatient hospital admissions (surgical, non-surgical, behavioral health, substance abuse) require prior authorization before the admission occurs.

Note

Emergency admission notification

In cases of emergency, notify the plan within one business day of admission.

Prior Authorization

Radiology prior authorization via Carelon for members over 18

Beginning 2026-01-01, preauthorization requirements for radiology for members over 18 are managed through Carelon (AIM). Use the Carelon web portal or contact center to initiate cases, check status, review guidelines, and view authorizations/eligibility.

Carelon web portal: https://guidelines.carelonmedicalbenefitsmanagement.com/
Carelon Contact Center: 1-800-859-5299
Effective date: 2026-01-01

Documentation Required

Medical necessity documentation required

Medical necessity must be documented and determined before a benefit preauthorization number will be issued; claims received without a benefit preauthorization number may be denied.

Prior Authorization

Follow preauthorization grid for category-specific services

Many service categories (for example: imaging, durable medical equipment, hospice, home health, surgeries, and special rehabilitation) require consulting the comprehensive preauthorization grid for the specific procedure codes and authorization steps. Providers should refer to the comprehensive preauthorization grid (PDF) for the list of codes that require review and the authorization process.

Background

This policy summarizes prior authorization and utilization management requirements for Blue Cross Blue Shield New Mexico Medicaid members. The policy directs providers to the comprehensive preauthorization grid (PDF) for the specific procedure codes that require review. Additionally, radiology prior authorization for members over 18 transitions to Carelon (AIM) effective 2026-01-01, and providers should use the Carelon web portal or contact center for adult radiology preauthorization management.

Definitions: I.H.S. = Indian Health Service; services provided by I.H.S. are exceptions to the prior authorization requirement.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicySummary of Services Requiring Prior Authorization for Medicaid

Policy CodePolicy N/A

Change TypeNo material change reported

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Summary of Services Requiring Prior Authorization for Medicaid

Coverage Summary

General Prior Authorization & Medical Necessity Criteria

Category-specific Preauthorization Criteria

Codes and Coding Notes

Provider Actions & Operational Requirements

Background

Revision History