Prior Authorization List — Individual & Family Markets and Fully Insured Groups
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Defines services that require prior authorization or recommended clinical review for Blue Cross Blue Shield of New Mexico members in individual & family markets and fully insured groups; affects providers submitting preservice requests and facility admissions planning.
No material clinical or coverage changes in this revision.
Coverage Criteria and Authorization Requirements
Elective Inpatient Facility Admissions
Covered when authorization is obtained prior to admission as required
Applies to listed facility types including acute care hospitals, residential treatment centers (RTC) and other inpatient facility settings.
Substance Use Disorder Inpatient Admissions Exception
Providers should still verify benefits and follow notification practices.
Pharmacy Prior Authorization/Step Therapy
Step therapy and specific prior authorization requirements for pharmacy benefits are defined in the Prior Authorization/Step Therapy Program and drug list guide.
Notification is required for in-network unplanned or emergency inpatient hospital care (including surgical, non-surgical, behavioral health and substance use disorder) — but notification is not required for out-of-network unplanned or emergency inpatient hospital care, including emergency admissions and stabilization care or services; notification of out-of-network emergency admissions is encouraged. [[chunk 0]]
Prior Authorization is required for all elective inpatient facility admissions (medical/surgical, mental health, residential treatment centers, inpatient substance use disorder rehabilitation, and other listed facility types) and must be obtained before the admission when required. For substance use disorder inpatient care there is an exception: planned elective SUD inpatient hospital care requires prior authorization except for the initial 4 days of in-network inpatient SUD care; providers should still verify benefits and follow notification practices. [[chunk 2]][[chunk 3]]
What Providers Must Do
Prior Authorization Required
Prior Authorization is required for certain services and preservice reviews. Providers must obtain prior authorization before delivering services that are listed as requiring authorization (see inpatient admissions, elective facility care, and specified procedures/medications). Obtain eligibility and benefits before requesting authorization to confirm membership, coverage, and whether prior authorization is required.
- Inpatient facility admissions (elective) require prior authorization
- Elective inpatient mental health and residential treatment center (RTC) admissions require prior authorization
- Planned elective substance use disorder inpatient rehab requires prior authorization (exceptions may apply for initial days)
Pharmacy Step Therapy / Prior Authorization Note
Some prescription drugs require step therapy or prior authorization under the pharmacy benefit. Refer to the Prior Authorization/Step Therapy Program information and the drug list guide to determine if a specific medication requires step therapy or prior authorization before it will be covered.
- Check the drug list guide for drug‑specific step therapy and prior authorization rules
- Follow the Prior Authorization/Step Therapy Program for required step edits before prescribing or dispensing
Verify Eligibility and Benefits
Verify eligibility and benefits prior to requesting authorization. Confirmation of eligibility and benefits and/or preauthorization is not a guarantee of payment; final payment determinations occur when a claim is received and are based on member eligibility and the terms of the member's certificate of coverage on the date of service.
- Obtain member eligibility and benefit information before requesting prior authorization
- Use available vendor tools (for example, Availity) to verify eligibility and benefits
Denial Risk for Lack of Authorization
Failure to obtain required prior authorization when it is listed as required may result in denial or noncoverage of the service. Notification requirements differ for in-network unplanned/emergency admissions (notification required) versus out-of-network unplanned/emergency admissions (notification encouraged but not required).
- Services requiring prior authorization that are provided without prior approval risk claim denial
- Notify facility admissions per network rules to avoid administrative denials
Policy Background
This policy defines two administrative preservice review processes used to determine benefits and medical necessity: Prior Authorization, which is required in advance for certain services, and Recommended Clinical Review, which is an elective preservice review for services that do not require authorization. The primary distinction is that authorization is mandatory for specified services while recommended clinical review is optional. [[chunk 0]]
Before requesting any preservice review, providers must obtain eligibility and benefits verification to confirm membership, coverage, and whether prior authorization is required. Failure to obtain required prior authorization for services that require preservice review may result in denial or determination of noncoverage at claim adjudication. [[chunk 0]][[chunk 5]]
Key Definitions
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