CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Prior Authorization Requirements for Inpatient and Selected Outpatient Services

This document explains BCBSNM's preservice review processes (prior authorization and recommended clinical review) and lists inpatient and selected outpatient services that require prior authorization; it applies to providers rendering care to BCBSNM members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrior Authorization Requirements for Inpatient and Selected Outpatient Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization before any planned (elective) inpatient admission and verify eligibility and benefits before requesting authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All planned inpatient admissionsRequires prior authorization

Notification requiredIn-network unplanned/emergency admissions

Service categoriesOutpatient services requiring prior auth

Prior auth requiredHome-based services

Preservice Review and Coverage Requirements

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Preservice review requirements

Covered only when prior authorization or notification requirements are met as described below

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

Determination based on MCG Criteria, Medical Policy, and member benefits

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 and do not require notification.

Notification, not prior authorization, for in-network emergencies

Out-of-network unplanned/emergency admissions: Notification is not required for out-of-network unplanned or emergency inpatient hospital care, including emergency admissions and post-stabilization care, though notification is encouraged.

Services requiring prior authorization

The following services require prior authorization where indicated

Inpatient facility types: Acute Care / Hospital; Long Term Acute Care / Sub-acute; Hospice Care; Rehabilitation Facility; Skilled Nursing Facility - prior authorization required for all inpatient services.

Other services: Dialysis from out-of-network providers; Home Health Services including home private duty nursing (PDN) and Home Infusion Therapy (HIT); Home Hospice; 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; selected outpatient specialties (advanced imaging, molecular genetic testing, musculoskeletal joint/spine surgery and pain, radiation therapy, sleep, select outpatient cardiology, ENT, gastroenterology, neurology, outpatient surgery, pain management, wound care).

List not exhaustive; specific billing codes not provided in document.

This policy distinguishes between prior authorization (a required preservice review for certain services) and notification/recommended clinical review. Prior authorization must be obtained in advance to determine medical necessity based on MCG Criteria, Medical Policy, and member benefits; providers should obtain eligibility and benefits first to confirm coverage and whether prior authorization is required. Failure to verify eligibility or obtain required authorizations may affect payment determination at claim adjudication.

Service Codes and Coding Notes

Services listed without specific codesmixed

Dialysis obtained from an Out-of-Network-Provider	Dialysis obtained from an Out-of-Network-Provider*
Home Health Services (including PDN and Home Infusion Therapy)	Home Health Services including but not limited to home private duty nursing (PDN) and home infusion therapy (HIT)*
Home Hospice	Home Hospice*
Home Infusion Therapy (HIT)	Home Infusion Therapy (HIT)*
Home Hemodialysis	Home Hemodialysis*
Non-Emergent Air Ambulance	Non-Emergent Air Ambulance*
Transplant Evaluations and Transplants	Transplant Evaluations and Transplants
Out-of-Network/Out-of-Plan Services	Out-of-Network/Out-of-Plan Services*
Outpatient elective surgery received in an out-of-network Hospital or ambulatory surgical center	Outpatient elective surgery received in an out-of-network Hospital or ambulatory surgical center*
Advanced Imaging / Radiology	Advanced Imaging / Radiology (Carelon)

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Provider Responsibilities and Authorization Process

Prior Authorization

Prior Authorization Required for Planned Inpatient Admissions

Prior authorization is required for all planned (elective) inpatient admissions and related inpatient services. This includes elective surgical and non-surgical admissions across acute care hospitals, inpatient rehabilitation, long-term acute care/sub-acute, skilled nursing facilities, hospice, and cardiac or pain management inpatient programs. Elective admissions must have prior authorization before the admission occurs.

Applies to in-network and out-of-network planned (elective) inpatient hospital care.
Includes surgical, non-surgical, behavioral health and substance abuse elective admissions.

Note

Verify Eligibility and Benefits Before Authorization Requests

Providers should verify member eligibility and benefits before requesting prior authorization. Verification confirms membership, coverage, and whether prior authorization is required for the requested service. Note that eligibility/benefit verification or prior authorization does not guarantee payment — final determination is made when a claim is received and is subject to the member’s certificate of coverage on the date of service.

Obtain eligibility and benefits first to confirm membership and coverage.
Verification limits and specifics may vary by plan; confirm prior to requesting authorization.

Denial Risk

Risk of Denial When Prior Authorization Is Not Obtained

If prior authorization is required and not obtained for a planned inpatient admission, the service may be denied or remain unpaid. Providers should obtain authorization prior to elective admissions to avoid potential denial of services or nonpayment.

Elective admissions without prior authorization are subject to denial.
Notification requirements differ for unplanned/emergency admissions; however notification does not replace required prior authorization for elective care.

Documentation Required

Provider Action and Contact Information

For services that do not require prior authorization, BCBSNM may use recommended clinical review (elective) to assess medical necessity. For services that do require prior authorization, contact BCBSNM Health Services Department for questions or to initiate the authorization process.

Contact BCBSNM Health Services Department at 800-325-8334 with questions.
Examples of other services that commonly require prior authorization include: advanced imaging, molecular genetic testing, certain musculoskeletal procedures, radiation therapy, home health and home infusion services, transplants, and non-emergent air ambulance.

OpenPayer

Prior Authorization Requirements for Inpatient and Selected Outpatient Services

Preservice Review and Coverage Requirements

Service Codes and Coding Notes

Provider Responsibilities and Authorization Process

Inpatient and Post-Acute Admission Criteria