CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Preauthorization Requirements List (Coverage Criteria)

This document lists services and scenarios that require preauthorization or predetermination from Blue Cross Blue Shield of New Mexico and summarizes preservice review expectations for providers and members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPreauthorization Requirements List (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionObtain eligibility and benefits prior to requesting preauthorization to confirm membership, coverage, and whether preauthorization is required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Inpatient servicesPlanned inpatient

Multiple outpatient categoriesOutpatient categories

Home-based servicesHome-based

Behavioral healthBehavioral health

Pharmacy prior authPharmacy

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Covered when preauthorization required

List of services requiring preauthorization: Preauthorization required for planned (elective) inpatient hospital care; inpatient medical/surgical facility admissions including acute care hospital, long-term acute care/sub-acute, hospice, rehabilitation facility, and skilled nursing facility; dialysis obtained from an out-of-network provider; home health services (including private duty nursing and home infusion therapy); home hospice; home infusion therapy; home hemodialysis; non-emergent air ambulance; transplant evaluations and transplants; out-of-network/out-of-plan services; outpatient elective surgery received in an out-of-network hospital or ambulatory surgical center; select outpatient medical/surgical services for FI & ASO members routed through AIM or BCBSNM (including advanced imaging, molecular genetic testing, musculoskeletal joint/spine surgery, musculoskeletal pain, radiation therapy, sleep services, cardiology lipid apheresis, and other select outpatient services); behavioral health and chemical dependency facility admissions (inpatient, partial hospitalization, residential treatment center); and certain behavioral health outpatient services (ABA, ECT, intensive outpatient treatment, psychological/neuropsychological testing, rTMS).

See document for full list and notes about AIM/BCBSNM routing and codes not provided.

Admission preauthorization requirement: Prior authorization is required for all planned (elective) inpatient admissions to acute care hospitals, long-term acute care/sub-acute, hospice, rehabilitation facilities, and skilled nursing facilities. Elective admissions must have authorization before the admission occurs.

In-network unplanned or emergency inpatient hospital care does not require notification; notification is not required for out-of-network unplanned or emergency inpatient hospital care though it is encouraged.

In-network unplanned or emergency inpatient hospital care, including surgical, non-surgical, behavioral health and/or substance abuse admissions, does not require notification. Notification is also not required for out-of-network unplanned or emergency inpatient hospital care (including emergency admissions and post-stabilization care or services), although notification of the admission to the facility is encouraged.

Provider Responsibilities and Prior Authorization Process

Prior Authorization

Preauthorization Required

Preauthorization is required for certain services including all planned inpatient admissions and a variety of outpatient, home-based, and specialty services. Obtain eligibility and benefits before requesting preauthorization to confirm membership, verify coverage, and determine whether preauthorization is needed. For questions contact BCBSNM Health Services at 800-325-8334.

All planned (elective) inpatient admissions require prior authorization (acute care, inpatient rehab, long-term acute care/sub-acute, skilled nursing, hospice, etc.).
In-network unplanned or emergency inpatient care does not require prior authorization; notification is encouraged for out-of-network emergency care.

Prior Authorization

Pharmacy and Specialty Drug Review

Some pharmacy benefits require prior authorization before a medication will be covered. Specialty pharmacy medications that are covered by medical benefits undergo medical necessity review: infusion site of care reviews for therapy and place of infusion, provider-administered drug therapies reviewed for therapy, and medical oncology & supportive care drugs reviewed (through AIM) when supported by an oncology diagnosis.

Check the drug lists/drug guide to determine whether a specific drug requires prior authorization.
Infusion site-of-care determinations and medical necessity reviews apply to specialty/infusion therapy and provider-administered drugs.

Documentation Required

Eligibility and Benefits Verification

Always obtain eligibility and benefits prior to requesting preauthorization to confirm member coverage and whether preauthorization or predetermination is required.

Verify member enrollment, plan benefits, and any preauthorization requirements before scheduling services or submitting requests.

Denial Risk

Denial Risk for Lack of Preauthorization

Failure to obtain required preauthorization may result in claim denial or reduced benefit. Providers are responsible for securing authorization for services listed as requiring preauthorization.

Services without required authorization (including elective inpatient admissions and listed outpatient or home-based services) are at risk for denial or limited payment.
Contact BCBSNM Health Services or follow AIM/BCBSNM guidance for listed outpatient services to avoid denial risk.

Facility Admission Prior Authorization

SNF | LTACH | IRF | hospice

Admission preauthorization requirement: Prior authorization is required for all planned (elective) inpatient admissions to acute care hospitals, long-term acute care/sub-acute, hospice care, rehabilitation facilities, and skilled nursing facilities. Elective admissions must have authorization before the admission occurs.

Preauthorization applies to surgical, non-surgical, behavioral health and substance use elective admissions.

Key Terms

Preauthorization (preservice review)

DefinitionPreauthorization is a preservice review required to determine in advance the medical necessity or experimental, investigational or unproven nature of certain care and services.

When requiredPreauthorization is required by BCBSNM for certain services (see policy list) and must be obtained before planned (elective) inpatient admissions and other listed services.

Basis for decisionDeterminations are made based on MCG criteria, Medical Policy, and Member benefits.

Action for providersObtain eligibility and benefits first to confirm membership, verify coverage, and determine whether preauthorization is required.

Predetermination (elective preservice review)

DefinitionPredetermination is an elective preservice review for services that do not require preauthorization to estimate coverage.

PurposeProvides an estimate of coverage and benefits when preauthorization is not required.

Voluntary naturePredetermination is optional — providers may request it when desired to clarify coverage for elective services that do not mandate preauthorization.

Policy Background

This administrative list aligns preauthorization requirements with medical necessity determinations based on MCG criteria, medical policy, and member benefits. It clarifies that preauthorization is a preservice review required for certain services to determine medical necessity or whether care is experimental, investigational, or unproven, while predetermination is an elective preservice review for services that do not require preauthorization. Providers should obtain eligibility and benefits before requesting preauthorization to confirm membership, coverage, and whether preauthorization is required; planned (elective) inpatient admissions must have authorization before the admission occurs.