What’s Changing: Blue Cross and Blue Shield of New Mexico (BCBSNM) is changing prior authorization requirements that may apply for some Administrative Services Only (ASO) commercial and/or Medicaid Blue Cross Community CentennialSM (BCCC) members to reflect new, replaced or removed codes. These changes are based on updates from Utilization Management prior authorization assessment, Current Procedural Terminology (CPT®) code changes released by the American Medical Association or Healthcare Common Procedure Coding System (HCPCS) changes from the Centers for Medicaid & Medicare Services. A summary of changes is included below.
Important Reminder: Always check eligibility and benefits first through the Availity® Provider Portal or your preferred vendor portal, prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.
Changes include:
- Jan. 1, 2024 – Expansion of the Musculoskeletal Joint & Spine category to include arthroscopy codes to be reviewed by Carelon Medical Benefits Management (Carelon)
- Jan. 1, 2024 – Addition of Specialty Pharmacy codes to be reviewed by BCBSNM
- Jan. 1, 2024 – Addition of Medical Oncology drug codes to be reviewed by Carelon
- Jan. 1, 2024 – Addition of Genetic Testing lab codes to be reviewed by Carelon (includes BCCC)
- Jan. 1, 2024 – Removal of Molecular Genetic Lab Testing, Musculoskeletal Pain, Joint and Spine, Radiation Therapy, Medical Oncology and Sleep care categories previously reviewed by Carelon for BCCC
- Jan. 1, 2024 – Addition of codes within the Proton Beam care category (which was previously reviewed by Carelon) to be reviewed by BCBSNM for BCCC
- Jan. 1, 2024 – Removal of miscellaneous codes previously reviewed by BCBSNM for BCCC
More Information: Refer to the updated Preauthorization CPT Code Lists section in the Pre Service Reviews area of the website. The code changes will be designated with dates of removal or addition.
Avoid post-service medical necessity reviews and delays in claim processing by obtaining prior authorization before rendering services. If prior authorization is required, services performed without prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.
CPT copyright 2022 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM.
Carelon Medical Benefits Management (Carelon) is an independent company that has contracted with BCBSNM to provide utilization management services for members with coverage through BCBSNM.
The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.