CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Prior Authorization Requirements for Inpatient and Select Outpatient Services

Defines BCBSNM's preservice review processes (prior authorization and recommended clinical review) and lists services requiring prior authorization; applicable to providers and facilities billing Blue Cross Blue Shield of New Mexico members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrior Authorization Requirements for Inpatient and Select Outpatient Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2023

Next Review DateSep 17, 2023

Key ActionObtain eligibility and benefits and secure prior authorization before all planned (elective) inpatient admissions and for specified outpatient and home services where required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All planned inpatient admissionsRequire prior authorization

Notification requiredIn-network unplanned/emergency inpatient admissions

Multiple listedOutpatient categories

Prior auth requiredHome-based services

Coverage & Notification Requirements

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Prior Authorization Requirements

Covered/authorized when prior authorization is obtained as required by service type

Planned inpatient admissions: Prior authorization required for all planned (elective) inpatient hospital care including surgical, non-surgical, behavioral health and substance abuse.

Elective admissions must have prior authorization before the admission occurs.

In-network unplanned/emergency admissions: Notification of admission to the facility is required for in-network unplanned or emergency inpatient hospital care; pre-stabilization and stabilization care are exceptions.

Notification, not prior authorization, for unplanned in-network admissions.

Outpatient and other services: Prior authorization required for specified services including certain home services, transplants, non-emergent air ambulance, and select outpatient services; specifics vary by member type and management vendor.

See policy for full list; verification of eligibility and benefits is recommended to determine if prior authorization is required.

For out-of-network unplanned or emergency inpatient hospital care the plan does not require prior authorization. Notification of the admission is not required, though the policy states that notification is encouraged. This exception applies to emergency and post-stabilization care; by contrast, in-network unplanned or emergency admissions do require notification and all planned (elective) inpatient admissions require prior authorization before the admission occurs.

Provider Responsibilities & Prior Authorization Process

Prior Authorization

Prior Authorization Required for Planned Inpatient Care

Prior authorization is required for all planned (elective) inpatient hospital care, including surgical, non-surgical, behavioral health and substance abuse admissions. Obtain prior authorization before the admission occurs. For in-network unplanned or emergency inpatient care, notify the facility of the admission; notification is encouraged but not required for out-of-network emergency admissions. For questions, contact BCBSNM Health Services at 800-325-8334.

Applies to acute care, inpatient rehab, cardiac rehab, pain management, skilled nursing, hospice, long-term acute/sub-acute care and similar inpatient settings.
Prior authorization is required for all inpatient services and inpatient transfers.
Notification is required for in-network unplanned/emergency inpatient admissions (except pre-stabilization/stabilization care).

Prior Authorization

Outpatient Prior Authorization (FI & ASO Members)

Outpatient prior authorization routes depend on member type. For Fully Insured (FI) and ASO members, certain outpatient medical/surgical services require prior authorization via Carelon Medical Benefits Management (formerly AIM) or BCBSNM as indicated. Verify which route applies before submitting requests.

Carelon handles: advanced imaging/radiology, molecular genetic testing, musculoskeletal joint and spine surgery, musculoskeletal pain procedures, radiation therapy/oncology, and select sleep services.
BCBSNM handles select outpatient services including certain cardiology (lipid apheresis), ENT, gastroenterology, neurology, specified outpatient surgeries, pain management, sleep studies (FI with BCBSNM), and wound care.
Refer to the downloadable Medical Surgical procedure code list for FI & ASO members to identify specific procedure codes requiring prior authorization.

Note

Verify Eligibility & Benefits Before Services

Obtain eligibility and benefits verification prior to providing services to confirm membership, coverage, and whether prior authorization is required. Verification should be completed for every member and service date.

Verification determines if prior authorization is required and identifies member-specific benefits and coverage limitations.
Use Availity or BCBSNM provider resources as appropriate to check eligibility and benefits.

Denial Risk

Prior Authorization and Eligibility Do Not Guarantee Payment

Remember that preauthorization, recommended clinical review, or eligibility verification does not guarantee payment. Final benefit determination is made when a claim is received and is subject to member eligibility and the terms of the member's certificate of coverage on the date of service.

Preauthorization confirms medical necessity or benefit eligibility in advance but does not guarantee claim payment.
Benefits and payment are determined upon claim submission based on the member's coverage at the time of service.

Note

Preservice Review Types & Provider Reminder

BCBSNM conducts two types of preservice review: required prior authorization for certain services and recommended clinical review for services that do not require prior authorization. If uncertain whether prior authorization is required, contact BCBSNM Health Services at 800-325-8334 for guidance.

Prior authorization determines in advance whether services meet Medical Necessity or are Experimental/Investigational/Unproven per MCG criteria, Medical Policy and member benefits.
Recommended clinical review is elective and may be used when prior authorization is not required.

OpenPayer

Prior Authorization Requirements for Inpatient and Select Outpatient Services

Coverage & Notification Requirements

Services and Code Listings

Provider Responsibilities & Prior Authorization Process

Facility Admission Categories