You may have seen the communication about the delayed launch of our new Laboratory Benefit Management program with Avalon Health Solutions (Avalon). We delayed this launch to continue providing education and clarity to providers about the program.
Effective Jan. 1, 2023, Blue Cross and Blue Shield of New Mexico (BCBSNM) will implement its new program with Avalon for claims for certain outpatient laboratory services provided to many of our commercial and BlueCard® (out of area) members.
This program does not apply at this time to government programs.
The new program will:
- Help our members access the right care at the right time and in the right setting
- Better prepare you to submit claims for covered services reflecting quality, affordable care delivery to our members
See below for key points and provider resources (including the self-service Trial Claim Advice Tool) to help you prepare.
Policy Updates
Watch for new and revised Clinical Payment and Coding Policies effective Jan. 1, 2023 related to certain laboratory services, tests, and procedures.
Affected Claims
Our new program may include:
- Outpatient laboratory claims with dates of service beginning Jan. 1, 2023
- Claims for services performed in an outpatient setting (typically office, hospital outpatient or independent laboratory)
Note: Laboratory services provided in an emergency room, hospital observation or hospital inpatient setting are excluded from this program. Member coverage terms still apply. Additionally, claim edits will not apply with respect to the age or gender of a patient.
Self-service Trial Claim Advice Tool via Availity® Essentials
We would like to give you the opportunity to better understand this change. Please use Avalon’s Trial Claim Advice Tool, in Availity, so you can become familiar with the program.
Since April 1, 2022, registered Availity users have had free access to Avalon’s Trial Claim Advice Tool, which is available 24/7. This tool allows you to input laboratory procedure and diagnosis codes to better understand the potential outcome of claims. Not registered for Availity? Sign up online today, at no cost.
Note: The Trial Claim Advice Tool does not guarantee approval, coverage, or reimbursement for health care services. Potential claim outcomes provided by Avalon’s Trial Claim Advice Tool consider information entered in the tool for the date of service, claims finalized through the prior business day, and applicable policies and/or guidelines.
For More Information
Continue to watch News and Updates for future program updates and training opportunities.
Avalon Health Solutions (Avalon) is an independent company that provides claims management services for members with coverage through BCBSNM. Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM. BCBSNM makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Avalon or Availity.