Prior Authorization List (Individual & Family Markets and Fully Insured Group Members)
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Describes services that require prior authorization or recommended clinical review for BCBSNM individual & family and fully insured group members and summarizes notification/authorization requirements affecting providers and members.
No material clinical or coverage changes in this revision.
Services Requiring Prior Authorization
Services requiring prior authorization
Covered when services meet plan rules and prior authorization is obtained where required:
Prior authorization determination is based on MCG Criteria, Medical Policy, and member benefits.
Pre-stabilization and stabilization care or services for emergency inpatient admissions are not subject to prior authorization or mandatory notification in the situations described by the plan. Specifically, for in-network unplanned or emergency inpatient hospital care (including surgical, non-surgical, behavioral health and substance use disorder), pre-stabilization and stabilization care or services are exceptions and do not require notification to the plan. Similarly, for planned elective substance use disorder inpatient admissions, prior authorization is required except for the initial 4 days of in-network inpatient SUD treatment, which are exempt from the prior authorization requirement.
Providers should continue to obtain eligibility and benefits information to confirm coverage and whether prior authorization is required for services beyond these exceptions, and contact the Health Services Department with questions.
In-network Inpatient SUD Initial Days Exemption
Provider Responsibilities and Prior Authorization Requirements
Prior Authorization Required
Prior authorization is required for certain inpatient admissions and all elective inpatient mental health and substance use disorder (SUD) care. Verify eligibility and benefits before initiating prior authorization. Note that authorization (or verification) is not a guarantee of payment; final benefit determination occurs at claim adjudication.
- Inpatient facility admissions: In-network unplanned or emergency inpatient hospital care requires notification of admission to the facility; notification is encouraged for out-of-network unplanned or emergency care. (See exceptions for pre-stabilization/stabilization care.)
- Mental health admissions: Prior Authorization is required for all elective inpatient facility care (e.g., inpatient, Residential Treatment Center) before the admission occurs.
- Substance use disorder admissions: Prior Authorization is required for planned elective inpatient SUD hospital care, except for the initial 4 days for in-network inpatient SUD treatment.
- Out-of-network exceptions and non-participating providers: Prior Authorization may be required for certain services — check member benefits.
- Authorization is not a guarantee of payment; benefits are determined upon claim receipt based on member eligibility and certificate terms.
Pharmacy Prior Authorization / Step Therapy
Some medications require a pharmacy prior authorization and may be subject to step therapy per the Pharmacy Benefits guide. Providers should check the drug list/Pharmacy Benefits prior authorization and step therapy program information to determine requirements for a specific drug.
- Review the Pharmacy Benefits drug list to confirm if a Prior Authorization is required for a medication.
- Some drugs may require step therapy before coverage is approved — follow the Step Therapy program guidance for Fully Insured members.
- Click the Prior Authorization/Step Therapy Program information (Pharmacy Benefits) to determine specific drug-level requirements.
Eligibility and Benefits Verification
Always verify member eligibility and benefits before providing services or initiating prior authorization to confirm coverage and determine whether prior authorization is required.
- Obtain eligibility and benefits first to confirm membership, verify coverage, and determine whether prior authorization is required.
- Contact BCBSNM Health Services Department at 800-325-8334 with questions.
Authorization Is Not a Guarantee of Payment
A prior authorization or eligibility verification does not guarantee payment. Final payment decisions are made at claim adjudication based on member eligibility and the terms of the member's certificate of coverage on the date of service.
- Preauthorization confirms that services meet medical necessity/coverage criteria at the time of review but does not override claim-level benefit or eligibility checks.
- Benefits will be decided once a claim is received and processed.
Policy Background
Blue Cross Blue Shield of New Mexico uses two types of preservice review to evaluate benefits and medical necessity: prior authorization and recommended clinical review. Prior authorization is required for specific services to determine in advance whether care is medically necessary or experimental/investigational based on MCG Criteria, Medical Policy, and member benefits, while recommended clinical review is an elective review for services that do not require prior authorization.
The preservice reviews apply across a range of facility-based and other services; providers should obtain eligibility and benefits first to confirm membership, verify coverage, and determine whether a preservice review is required. For assistance, providers may contact the BCBSNM Health Services Department.
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