Summary of Medical/Surgical and Behavioral Health Services, and Specialty Pharmacy Drugs Requiring Prior Authorization for Administrative Only (ASO) Members Form

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

PRIOR AUTHORIZATION

REQUIREMENTS LIST FOR ADMINISTRATIVE SERVICES ONLY (ASO) GROUPS EFFECTIVE 01/01/2025 • Blue Cross Blue Shield of New Mexico has two types of preservice review to assess benefits and medical necessity: prior authorization and recommended clinical review. Similarities predominate over differences between these two types of preservice review. The primary difference is that prior authorization is required for certain services whereas recommended clinical review is elective for services that do not require prior authorization.

• Prior Authorization is required by BCBSNM for certain services to determine in advance the Medical Necessity or Experimental, Investigational and/or Unproven nature of certain care and services based on MCG Criteria, Medical Policy, and Member benefits. The list below describes the services that require Prior Authorization.

• Eligibility and Benefits Reminder: Obtain eligibility and benefits first to confirm membership, verify coverage, and determine if prior authorization is required.

• If you have any questions, please contact the BCBSNM Health Services Department at 800-325-8334.

• Inpatient Facility Admission (acute care, inpatient rehab, cardiac rehab, pain management, skilled nursing, hospice, long term acute care/sub- acute care, etc.)

o Prior authorization is required for all planned (elective) inpatient hospital care, including surgical, non-surgical, behavioral health and/or substance abuse. Elective admissions must have prior authorization before the admission occurs.

o In-network unplanned or emergency inpatient hospital care (surgical, non-surgical, behavioral health and/or substance abuse) requires notification of admission to the facility. Pre-stabilization and stabilization care or services are exceptions and don’t require notification.

o Notification is not required for out-of-network unplanned or emergency inpatient hospital care (surgical, non-surgical, behavioral health and/or substance abuse), including emergency admissions and post-stabilization care or services. However, notification of admission to the facility is encouraged.

2025 Prior Authorization Requirements Inpatient Medical/Surgical Facility Admissions Including Transfers:
• Acute Care / Hospital
• Long Term Acute Care / Sub-acute
• Hospice Care
• Rehabilitation Facility
• Skilled Nursing Facility
Note: Prior Authorization is required for all inpatient services.
Other services that require Prior Authorization includes but not limited to:
Outpatient Medical/Surgical Services for ASO Members (through Carelon Medical Benefits Management when applicable or BCBSNM as indicated below) *
• Advanced Imaging / Radiology (Carelon)
• Molecular Genetic Lab Testing (Carelon)
• Musculoskeletal - Joint, Spine Surgery (Carelon)
• Musculoskeletal - Pain (Carelon)
• Radiation Therapy / Radiation Oncology (Carelon)
• Sleep (Carelon)

PRIOR AUTHORIZATION SERVICES FOR OTHER ADMINISTRATIVE SERVICES ONLY (ASO) MEMBERS EFFECTIVE 01/01/2025 Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association • Dialysis obtained from an Out-of-Network- Provider
• Home Health Services including but not limited to home private duty nursing (PDN) and home infusion therapy (HIT)
• Home Hospice
• Home Infusion Therapy (HIT)
• Home Hemodialysis
• Non-Emergent Air Ambulance
• Transplant Evaluations and Transplants
• Out-of-Network/Out-of-Plan Services
o Outpatient elective surgery received in an out-of-network Hospital or ambulatory surgical center
*Codes not available.

• Select Outpatient Services including but not limited to: (BCBSNM)
o Cardiology – Lipid Apheresis
o Ear, Nose and Throat
o Gastroenterology
o Neurology
o Outpatient Surgery (Breast, Deactivation of Headache Triggers, Jaw)
o Pain Management
o Wound Care
Codes not available.
*Note: Click here to view or download a list of Medical Surgical procedure codes that requires Prior Authorization for ASO Members.

Pharmacy Benefits (Prime):
Prior Authorization is required on some medications before drug will be covered. Check the drug list guide if Prior Authorization is required for a specific drug. 
*Note: Click here to view Prior Authorization/Step Therapy Program information to determine if the drug requires Prior Authorization under Pharmacy Benefits for certain ASO Groups.
Specialty Pharmacy Medications that are covered by Medical Benefits**
• Infusion Site of Care - medical necessity review required for therapy and for place of infusion.
• Provider Administered Drug Therapies - medical necessity review required for therapy only.
• Medical Oncology & Supportive Care (through Carelon) – medical necessity review required for oncology drugs that are supported by an oncology diagnosis

**Note: Click here to download a list of Specialty Pharmacy procedure codes that requires Prior Authorization for Administrative Services Only (ASO) Members.

Mental Health and Substance Use Disorder Facility Admissions:
• Inpatient
• Residential Treatment Center (RTC)
Mental Health and Substance Use Disorder Services Outpatient:
• Applied Behavioral Analysis (ABA)*
• Electroconvulsive Therapy
• Intensive Outpatient Treatment
• Partial Hospitalization
• Psychological Testing/Neuropsychological Testing
• Repetitive Transcranial Magnetic Stimulation**

*Codes not available.

**Note: Click here to view or download a list of Mental Health procedure codes that requires Prior Authorization for ASO Members

For a comprehensive list of services that might require Prior Authorization and an overview of the Prior Authorization process and requirements at Blue Cross and Blue Shield of New Mexico (BCBSNM), refer to Section 10   of the Blues Provider Reference Manual  .

Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized or predetermined for benefits is not a guarantee of payment. Benefits will be decided once a claim is received. They will be based

PRIOR AUTHORIZATION SERVICES FOR OTHER ADMINISTRATIVE SERVICES ONLY (ASO) MEMBERS EFFECTIVE 01/01/2025 Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association on, among other things, the member’s eligibility, and the terms of the member’s certificate of coverage effective on the date of service.
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 Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.