Blue Cross and Blue Shield of New Mexico (BCBSNM) has two types of preservice review to assess benefits and medical necessity: prior authorization and predetermination. Similarities predominate over differences between these two types of preservice review. The primary difference is that prior authorization is required for certain services whereas predetermination is elective for services that do not require prior authorization. Once requested, prior authorization and predetermination are processed in the same manner including, but not limited to, which reviewers are qualified to approve and deny, timelines, and notices, including appeal rights. Furthermore, neither prior authorization nor predetermination guaranty benefits or payment because, for example, member eligibility and benefits are reassessed as of the date of service and the circumstances represented in the request must have been complete and accurate and remain materially the same as of the date of service.
Eligibility and Benefits Reminder: Obtain eligibility and benefits first to confirm membership, verify coverage and determine whether or not prior authorization is required.
Prior authorization is required for all inpatient services.
For an overview of the prior authorization process and requirements at BCBSNM, refer to Section 10 of the BCBSNM Provider Reference Manual.
Medicaid Prior authorization: To obtain prior authorization for services for Medicaid members, please use the form found under prior authorization Requirements on the Medicaid webpage.
Request, Verify or Obtain Prior authorization
Participating Providers are required to request prior authorization on the member's behalf in accordance with the member's evidence of coverage; failure to do so may result in denial of the provider's claim and the member cannot be balance billed. Providers should complete the Prior authorization Request form. Prior authorization may also be requested by calling the prior authorization phone number listed on the back of the member's ID card.
- Electronic requests – Submit electronic prior authorization requests and inquiries (ANSI 278 transactions) through Availity®
or your preferred electronic health information technology vendor. Providers may submit the NM Uniform Prior Authorization Form electronically through Availity by attaching it during the request process. - Fax request – Complete the Prior authorization Request form o la NM Uniform Prior Authorization Form and submit it along with your supporting documentation
- Telephone Inquiries – Call the prior authorization number on the back of the member's ID card. Or, call our Health Services department at 800-325-8334 or 505-291-3585.
- Third-party prior authorization – prior authorization for certain services may be managed by a third party such as eviCore Health™
- Contact Information for NM Uniform Prior Authorization Form
If you have any questions, please contact the BCBSNM Health Services Department at 800-325-8334.
Prior authorization does not guarantee payment. All payments are subject to determination of the insured person's eligibility, payment of required deductibles, copayments and coinsurance amounts, eligibility of charges as covered expenses, and application of the exclusions and limitations and other provisions of the policy at the time the services are rendered.
Predetermination
A Predetermination is a written request to assess benefits and medical necessity prior to rendering services. Unlike prior authorization, which is mandatory for certain services, predetermination is elective for certain services not subject to prior authorization. Additionally:
- A predetermination is not a substitution for prior authorization.
- Always check benefits before submitting a predetermination. A predetermination is not available for all procedures. For example, predetermination may not be available for complete or partial bony impacted teeth.
- Fill out the entire Predetermination Request form.
- Always provide procedure code(s) and diagnosis code(s).
- If applicable, provide left, right or bilateral.
- Regarding major diagnostic tests, please include the patient’s history, physical and any prior testing information.
- If indicated, include original photos or digital color copies that clearly show the affected area of the body. This information must be mailed to the address indicated on the Predetermination Request form.
How to Submit a Request for Review
- Electronic request – Submit requests online using Availity's Attachments tool.
- Fax request – Complete the Predetermination Request Form and submit it along with supporting documentation.
- You will be notified when a final outcome has been reached
Predetermination does not guarantee payment. All payments are subject to determination of the insured person's eligibility, payment of required deductibles, copayments and coinsurance amounts, eligibility of charges as covered expenses, application of the exclusions and limitations, and other provisions of the policy at the time services are rendered.
vigente a partir del 01/01/2022