CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Prior Authorization Requirements for Inpatient and Select Services

Defines BCBSNM preservice review processes (prior authorization and recommended clinical review) and lists services that require prior authorization, affecting providers and facilities seeking coverage for planned inpatient and selected outpatient services for BCBSNM members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrior Authorization Requirements for Inpatient and Select Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 18, 2023

Next Review DateN/A

Key ActionObtain prior authorization before any planned (elective) inpatient admission for listed facility types.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All planned inpatientrequires prior authorization

Emergency admissionsnotification not required

Multiplefacility types listed

Some drugspharmacy prior auth

Coverage and Prior Authorization Criteria

Prior Authorization Coverage Criteria

Covered when prior authorization is obtained as required.

Elective inpatient admissions: Prior authorization must be obtained before any planned (elective) inpatient hospital admission (surgical, non-surgical, behavioral health, substance abuse).

Based on MCG Criteria, Medical Policy, and member benefits; elective admissions must have prior authorization before the admission occurs.

Facility types requiring prior authorization: Includes elective acute care/hospital, long term acute care/sub-acute, hospice care, rehabilitation facility, and skilled nursing facility.

See facility list in document; prior authorization is required for planned (elective) admissions to these facilities.

Pharmacy: Certain medications require prior authorization under Pharmacy Benefits; check the drug list guide for details.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrior Authorization Requirements for Inpatient and Select Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 18, 2023

Next Review DateN/A

Key ActionObtain prior authorization before any planned (elective) inpatient admission for listed facility types.

SourceLink

On This Page

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Provider Responsibilities and Authorization Process

Prior Authorization

Prior Authorization Required

Prior authorization is required by BCBSNM for certain services to determine medical necessity or whether care is experimental, investigational, or unproven. Prior authorization is required for all planned (elective) inpatient hospital care (including surgical, non-surgical, behavioral health and substance abuse) and for specified facility types listed below. Elective admissions must have prior authorization before the admission occurs.

Inpatient Acute Care / Hospital
Long Term Acute Care / Sub-acute
Rehabilitation Facility
Skilled Nursing Facility
Hospice Care
Behavioral Health Inpatient
Residential Treatment Center (RTC)

Step Therapy

Pharmacy Prior Authorization / Step Therapy

Some medications under BCBSNM Pharmacy Benefits require prior authorization or step therapy before the drug will be covered. Check the drug list guide or the Prior Authorization/Step Therapy Program information to determine whether a specific medication requires prior authorization under Pharmacy Benefits for Fully Insured members.

Note

Eligibility, Benefits, and Verification

Obtain eligibility and benefits before requesting services to confirm membership, verify coverage, and determine whether prior authorization is required. If you have questions about eligibility, benefits, or whether a service needs prior authorization, contact the BCBSNM Health Services Department at 800-325-8334.

Denial Risk

Risk of Denial for Missing Prior Authorization

If prior authorization is required and not obtained prior to a planned service (including elective inpatient admissions and other services listed as requiring prior authorization), the claim may be denied or not covered. Verification of eligibility and prior authorization does not guarantee payment — final benefits are determined when a claim is received based on member eligibility and the terms of the certificate of coverage on the date of service.

Facility Types Requiring Authorization

SNF | LTACH | IRF | hospice | acute care

Planned (elective) admissions to the following facility types require prior authorization before admission.

Admission prior auth needed: Planned admissions to inpatient acute care, long term acute care/sub-acute, rehabilitation facility, skilled nursing facility, inpatient rehab, and hospice require prior authorization before admission.

Elective admissions must have prior authorization before the admission occurs; notification is not required for unplanned or emergency inpatient care.

Key Definitions

inv-08: Prior Authorization

DefinitionA required preservice review to determine in advance the Medical Necessity or whether a service is Experimental, Investigational, and/or Unproven based on MCG Criteria, Medical Policy, and member benefits.

ScopeRequired for certain services including all planned (elective) inpatient hospital care (surgical, non-surgical, behavioral health, and substance abuse) and specified facility types such as acute care, inpatient rehabilitation, long term acute/sub-acute care, skilled nursing facility, and hospice.

TimingMust be obtained before the admission occurs for elective inpatient admissions.

PurposeTo assess benefits and medical necessity prior to service delivery and to determine if services are experimental or investigational.

Provider actionObtain eligibility and benefits first to confirm membership and determine whether prior authorization is required; contact BCBSNM Health Services Department with questions.

inv-09: Recommended Clinical Review

DefinitionAn elective preservice review option for services that do not require prior authorization.

Similarity to prior authFunctions as a preservice review to assess benefits and medical necessity, with similarities to prior authorization except it is not mandatory.

Use caseOffered for services where prior authorization is not required but a provider seeks advance determination of coverage or medical necessity.

Process noteObtain eligibility and benefits first to confirm membership and determine whether recommended clinical review or prior authorization is appropriate.

Policy Background

BCBSNM uses two preservice review processes to evaluate benefits and medical necessity: Prior Authorization and Recommended Clinical Review. The key distinction is that Prior Authorization is required in advance for specified services to determine medical necessity or whether services are experimental, investigational, or unproven, while Recommended Clinical Review is an elective option for services that do not require prior authorization. Prior authorization decisions are based on MCG Criteria, Medical Policy, and member benefits. Providers should obtain eligibility and benefits verification before requesting preservice review and contact BCBSNM Health Services with questions.