Inpatient Facility Admission — Prior Authorization and Notification Requirements
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Defines BCBSNM prior authorization and notification requirements for inpatient facility admissions and related services affecting individual & family markets and fully insured group members effective 01/01/2026.
No material clinical or coverage changes in this revision.
Coverage and Notification Criteria
Admission-type authorization criteria
Prior authorization or notification requirements by admission type:
Pre-stabilization and stabilization of care or services are exceptions and do not require notification.
Notification is encouraged but not required.
Applies to inpatient medical/surgical, mental health (including RTC), and other elective inpatient settings.
Initial in-network SUD inpatient stay is covered without prior authorization for the first 4 days; prior authorization required thereafter for the admission to continue.
Pre-stabilization and stabilization of care or services are exceptions to the notification requirement for in‑network unplanned or emergency inpatient hospital admissions. When a member presents for unplanned or emergency care (surgical, non‑surgical, behavioral health, or substance use), notification of admission to the facility is required except for pre‑stabilization and stabilization services, which do not require notification.
Notification is not required for out‑of‑network unplanned or emergency inpatient hospital care (including surgical, non‑surgical, mental health, and substance use disorder admissions), including emergency admissions and post‑stabilization care or services; however, notification to the facility is encouraged.
Services that are determined to be not medically necessary or that are considered experimental, investigational and/or unproven may be subject to prior authorization and may be denied if not authorized. Prior authorization is used to determine medical necessity or investigational status in advance, based on MCG Criteria, Medical Policy, and member benefits.
What Providers Must Do
Prior authorization required for specified inpatient admissions
Prior authorization is required for elective inpatient facility admissions across medical/surgical settings (acute care, LTAC/sub-acute, hospice, rehabilitation, skilled nursing), all elective inpatient mental health admissions including residential treatment centers, and planned elective substance use disorder inpatient rehab admissions (with an exception for the initial 4 days for in-network SUD treatment).
- Applies to inpatient medical/surgical admissions including transfers: Acute care/hospital, LTAC/sub-acute, hospice, rehabilitation, and skilled nursing.
- Applies to all elective inpatient mental health admissions and Residential Treatment Center stays.
- Applies to planned elective substance use disorder inpatient rehab admissions; initial 4 days for in‑network SUD inpatient treatment are excepted from PA.
Pharmacy prior authorization note
Some medications under the pharmacy benefit require prior authorization before the drug will be covered; check the BCBSNM drug list guide and the linked Prior Authorization/Step Therapy Program information to determine whether a specific medication requires pharmacy PA or step therapy.
- Use the drug list guide to confirm if a specific medication requires prior authorization.
- Refer to the Prior Authorization/Step Therapy Program page for Fully Insured members for program details.
Verify eligibility and benefits before requesting authorization
Obtain eligibility and benefits verification before initiating services to confirm member enrollment, verify coverage, and determine whether prior authorization is required for the planned admission or service.
- Eligibility and benefits verification is required to confirm membership and whether PA is necessary.
- Verification does not guarantee payment; final benefits are determined at claim adjudication.
Consequence of not obtaining required prior authorization
Services that require prior authorization but are not preauthorized may be denied if they are later determined to be not medically necessary or considered experimental, investigational, or unproven.
- Failure to obtain required prior authorization risks claim denial on medical necessity or investigational grounds.
- Preauthorization or recommended preservice review should be completed in advance for services listed as requiring PA.
Key Definitions
Site-of-Care Notes
Verify pharmacy PA for infusion center-administered drugs
For infusion center or other site-of-care drug administration, verify pharmacy benefit prior authorization requirements via the drug list guide and linked prior authorization/step therapy program information to confirm whether the medication requires prior authorization.
Pharmacy Prior Authorization / Step Therapy
| Step | Requirement |
|---|---|
| 1 | Refer to BCBSNM Prior Authorization/Step Therapy Program information to determine if a drug requires prior authorization under Pharmacy Benefits for Fully Insured members. For specific drugs, check the drug list guide to see if prior authorization is required. |
Policy Background
This document provides administrative guidance describing when Blue Cross Blue Shield of New Mexico requires prior authorization or notification for inpatient admissions across medical/surgical, behavioral health, and substance use disorder settings. Obtain eligibility and benefits before initiating a request to confirm membership and determine whether prior authorization is required. The policy distinguishes notification requirements for in‑network unplanned/emergency admissions (notification required, except for pre‑stabilization and stabilization) from out‑of‑network unplanned/emergency admissions (notification not required but encouraged), and identifies when prior authorization is required for elective inpatient admissions and other specified services.
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