CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Prior Authorization and Predetermination Requirements

This policy describes BCBSNM's preservice review processes (prior authorization and predetermination), the types of services that require prior authorization, and guidance for providers on verification and notification. It affects providers caring for BCBSNM members (Fully Insured and ASO).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrior Authorization and Predetermination Requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2023

Next Review DateN/A

Key ActionObtain eligibility and benefits prior to services to confirm membership, verify coverage and determine whether prior authorization is required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All planned inpatient servicesRequire prior authorization

Multiple outpatient categoriesOutpatient categories

Pharmacy prior authPharmacy prior auth

Specialty pharmacySpecialty pharmacy & infusion

Behavioral healthBehavioral health admissions

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Services and Coverage Criteria

Services Requiring Prior Authorization

Covered when prior authorization requirements are met for listed services

Prior Authorization Required: Prior authorization must be obtained for all planned (elective) inpatient hospital care, including surgical, non-surgical, behavioral health and substance abuse admissions, before the admission occurs.

Elective admissions must have prior authorization before the admission.

Inpatient settings included: Applies to acute care/hospital, long term acute care/sub-acute, hospice care, rehabilitation facility and skilled nursing facility admissions.

Other services requiring prior authorization: Prior authorization is required for specified other services including dialysis from out-of-network providers; home health services (including private duty nursing and home infusion therapy); home hospice; home hemodialysis; non-emergent air ambulance; transplant evaluations and transplants; and outpatient elective surgery received out-of-network.

See downloadable lists for codes where available.

Outpatient, Pharmacy, and Specialty Therapies

Covered with prior authorization/medical necessity review as indicated

Outpatient advanced and specialty services: Certain outpatient services require prior authorization or medical necessity review, including advanced imaging/radiology, molecular genetic laboratory testing, musculoskeletal procedures (joint/spine surgery and musculoskeletal pain), radiation therapy/radiation oncology, and selected outpatient services such as cardiology (lipid apheresis), ENT, gastroenterology, neurology, select outpatient surgeries (breast, deactivation of headache triggers, jaw), pain management, sleep studies, and wound care.

Some outpatient services route through AIM or BCBSNM as indicated; click to view or download Medical Surgical procedure code lists for FI & ASO members.

Behavioral Health services: Behavioral health and chemical dependency facility admissions (inpatient and residential treatment center) and outpatient behavioral health services (e.g., ABA, ECT, intensive outpatient, partial hospitalization, psychological/neuropsychological testing, repetitive TMS) require prior authorization or review as specified.

Behavioral health inpatient admissions are treated as planned inpatient services and require prior authorization; notification rules differ for unplanned/emergency admissions.

Pharmacy and specialty pharmacy therapies:

Notification is not required for out-of-network unplanned or emergency inpatient hospital care, including emergency admissions and post-stabilization care or services. While BCBSNM encourages notification of such admissions to the facility, pre-stabilization and stabilization care or services are exceptions and do not require notification.

By contrast, prior authorization is required for all planned (elective) inpatient hospital care — including surgical, non-surgical, behavioral health and substance abuse admissions — and must be obtained before the admission occurs. For outpatient behavioral health services, certain services (for example, ABA, ECT, intensive outpatient, partial hospitalization, psychological/neuropsychological testing, and repetitive TMS) may require prior authorization; refer to downloadable mental health procedure code lists for details.

Codes and Billing Categories

Inpatient Facility AdmissionsmixedCovered

Not provided

Inpatient Medical/Surgical Facility Admissions including Acute Care / Hospital, Long Term Acute Care / Sub-acute, Hospice Care, Rehabilitation Facility, Skilled Nursing Facility

Outpatient Services requiring prior authorizationmixedCovered

Not provided

Outpatient services: Advanced Imaging / Radiology (AIM), Molecular Genetic Lab Testing (AIM), Musculoskeletal - Joint/Spine Surgery (AIM), Musculoskeletal - Pain (AIM), Radiation Therapy / Radiation Oncology (AIM), Sleep (ASO with AIM), Select Outpatient Services (cardiology lipid apheresis, ENT, gastroenterology, neurology, certain outpatient surgeries, pain management, sleep studies, wound care)

Behavioral Health ServicesmixedCovered

Not provided	Behavioral Health and Chemical Dependency Facility Admissions (Inpatient, Residential Treatment Center)
Not provided	Behavioral Health outpatient services: Applied Behavioral Analysis (ABA), Electroconvulsive Therapy (ECT), Intensive Outpatient, Partial Hospitalization, Psychological/Neuropsychological Testing, Repetitive Transcranial Magnetic Stimulation (rTMS)

Pharmacy / Specialty PharmacymixedCovered

Not provided

Pharmacy prior authorization required for some medications under Pharmacy Benefits; Specialty Pharmacy medications covered by Medical Benefits (infusion site of care, provider administered drug therapies, medical oncology & supportive care) require medical necessity review and prior authorization for procedure codes

Other services requiring prior authorizationmixedCovered

Not provided

Home health services (including private duty nursing and home infusion therapy), Home Hospice, Home Hemodialysis, Non-Emergent Air Ambulance, Transplant evaluations and transplants, Out-of-Network/Out-of-Plan services, Dialysis from an Out-of-Network Provider

Provider Responsibilities and Authorization Process

Prior Authorization

Obtain prior authorization for all listed planned inpatient and specified outpatient services

Prior authorization must be obtained for all planned (elective) inpatient hospital care and for the outpatient services and other categories specifically listed by BCBSNM (see policy lists and downloadable code lists). Elective inpatient admissions must have prior authorization before the admission occurs.

All planned (elective) inpatient hospital care (surgical, non-surgical, behavioral health, substance abuse) requires prior authorization.
Specified outpatient categories (advanced imaging, molecular genetic testing, musculoskeletal procedures, radiation therapy, select outpatient surgeries, sleep services, etc.) require prior authorization or medical necessity review as indicated.
Other services listed (home health/PDN, home infusion, home hospice, transplant evaluations, non-emergent air ambulance, out-of-network elective surgery, etc.) require prior authorization.

Prior Authorization

Verify pharmacy prior authorization requirements via the drug lists

Some medications require prior authorization under Pharmacy Benefits; check the drug list guide to determine whether a specific drug requires prior authorization.

Background and Rationale

BCBSNM uses preservice review processes to determine benefit coverage and medical necessity. There are two types: Prior Authorization, which is required for certain services to determine medical necessity or whether a service is experimental, investigational, or unproven (based on MCG Criteria, Medical Policy and member benefits), and Predetermination, which is an elective preservice review for services that do not require prior authorization.

Providers should obtain eligibility and benefits prior to services to confirm membership, verify coverage, and determine whether prior authorization is required. If there are questions about requirements or the process, contact the BCBSNM Health Services Department at 800-325-8334.

Definitions

Prior Authorization — definition

DefinitionA preservice review required to determine in advance the medical necessity or whether a service is experimental, investigational, or unproven based on MCG Criteria, Medical Policy and member benefits.

When requiredPrior authorization is required for certain services listed by BCBSNM, including all planned (elective) inpatient hospital care and specified outpatient and specialty services.

TimingMust be obtained before the service occurs; elective admissions must have prior authorization before admission.

PurposeTo assess benefits and medical necessity and to determine whether care is experimental, investigational and/or unproven.

Provider actionObtain eligibility and benefits first to confirm membership, verify coverage and determine whether prior authorization is required; contact BCBSNM Health Services for questions.