Transparency in Coverage

The provider network that is available to you under the terms of your plan is made up of independently contracted doctors, hospitals and other health care providers. The contracted providers in your network do not work for nor are part of BCBSNM. However, they do have agreements with BCBSNM that may help save you money for covered services.

Your costs will vary depending on whether your provider is participating in the network. Please refer to Provider Finder^® to find in-network providers. You should check if your plan has out-of-network benefit coverage before scheduling a visit.

The way you use the provider network available under your health plan may vary by your plan type. 

• Learn more about HMO plans

Sometimes, to receive benefits for certain services or prescription drugs, you or your provider should call BCBSNM before you receive treatment. Please refer to the Benefit Booklet's section titled "Utilization Management" for more information regarding Prior Authorization and Recommended Clinical Review.  Note that this is different than getting a referral to see a specialist. Sometimes, you may need to get a referral to see a specialist and prior authorization to receive benefits for a service from that specialist. You can work with your doctor on determining when you need each.

When you or your provider contact BCBSNM with a request for Prior Authorization or Recommended Clinical Review, we will ask for some information regarding the care or treatment that is proposed, which may include the following:

• Information about your medical condition
• The proposed treatment plan
• The estimated length of stay (if you are being admitted)

During the process, BCBSNM or a company on our behalf reviews the requested service or medication to see if the service or medication is medically necessary.

"Medically Necessary" is defined in your benefit booklet and generally refers to health care services that:

• are appropriate or necessary for either the diagnosis or direct care and treatment of a medical condition or injury; and
• follow generally accepted principles of good medical care, based on federal or professional practice guidelines.

The service or treatment must meet your plan's definition of medical necessity in order to be eligible for benefits under your plan. The Utilization Management process is not a substitute for the medical advice of your health care provider. The final decision to receive any medical service or treatment is between you and your health care provider.

Additional information, including links to plan documents, can be found here.

If you are unsure which health care services or medications require prior authorization, you can call the Customer Service number on your BCBSNM member ID card.

Remember, even if a service or medication is authorized, your benefit is still subject to eligibility review.  And if the provider is out of network you will likely pay more out-of-pocket. Check with your provider  to ensure the provider will be in your plan's network at the time of service. Also, a determination that a service is authorized or medically necessary is not a guarantee of coverage. The applicable terms of your plan will control the benefits that you will receive.

For HMO members:  Contact your primary care provider (PCP) to coordinate your care. If you are seeking care from a specialist, ask your PCP to ensure that you have received any needed prior authorization.

For all members:  Your in-network provider is responsible for obtaining prior authorization for your services. If your provider's request for prior authorization is denied, you have the right to appeal the decision. You can learn more about the appeals process in the Why Was Payment for the Service I Received Denied? section. You can also refer to your benefits documents or call the Customer Service number listed on your BCBSNM member ID card.

You may request a medical necessity review for services that do not require prior authorization. A Recommended Clinical Review is an optional medical necessity review conducted before services are provided.  If you are not sure about coverage or whether we may consider your service medically necessary at the proposed site of care, you can work with your provider to submit a request for Recommended Clinical Review. Submitting a Recommended Clinical Review does not guarantee coverage.

To determine if a Recommended Clinical Review is available for a specific service, visit our website for the Recommended Clinical Review list, which is updated when new services are added or when services are removed.  

The time it usually takes BCBSNM to respond to your Prior Authorization or Recommended Clinical Review request depends on a number of factors, including when we receive your information,and  the type of service or medication being requested, if additional information is needed and certain regulatory requirements.

For HMO members: Your primary care provider (PCP) helps coordinate your in-network care.

The following information generally shows how soon after BCBSNM receives a prior authorization request that you (or your provider) can expect to get a response. Additional guidelines may apply to these timelines and the time periods may be affected if additional information is needed or if additional information is submitted after the initial request.

NOTE: This information is not intended as medical advice or a substitute for medical advice. The final decision about any care or treatment you receive is between you and your health care provider. Check your plan details for more information.

• Non-Urgent Care requested before you receive services or for services you are currently receiving that have extended past the initial benefit approval
  
  • We will issue a notification in 7 business day.  
    
• Urgent Care^* requested before you receive services
  
  • We will make a decision no later than 24 hours after we receive the request.
    
• Urgent Care^* for inpatient services you are currently receiving and/or if you are hospitalized
  
  • If you request an extension of urgent care services at least 24 hours before your previously approved benefit for services expires, we will make a decision within 24 hours
  • If you request an extension of urgent care services with less than 24 hours remaining in your previously approved benefit for services, we will make a decision within 24 hours. 

* Urgent care is treatment that, when delayed, could seriously jeopardize your life and health or your ability to regain maximum function.

If you and your health care provider are requesting benefit authorization after you have already received services, BCBSNM will notify you or your provider with a coverage decision within 30 days.

In addition to the above, the following applies to all required prior authorizations:

• Neither Prior Authorization nor approved Recommended Clinical Review guarantees payment by your plan. Even if a service or medication has been authorized, coverage or payment can still be affected for a variety of reasons. For example, you may have become ineligible or have different coverage as of the date of service.
• We may request additional information. BCBSNM may require more information from your provider during the Prior Authorization or Recommended Clinical Review process. This could include a written explanation of the requested services, reasons for service and proposed site of care, projected outcome, cost statements or other documents that could be helpful to decide on the medical necessity of the treatment.
• You are responsible for making sure your prior authorization requirements are met. All health insurance and HMO health plans require prior authorization for certain services. When you stay in network, your provider may take care of this step for you, but you should always ask your doctor to make sure. If you decide to see an out-of-network provider, you are responsible for this step as well as additional amounts the out-of-network provider may charge you. Additional information, including links to plan documents, can be found here.

If you don't get prior authorization for a service that requires it, you may be responsible for a charge in addition to any other applicable deductibles, copayments or coinsurance. In addition, we may review the service to determine if it is medically necessary as defined in your benefit booklet. If we determine that the treatment(s) does not meet the definition of medically necessary, you may be responsible for paying for the services you received.

Whether you take medication to manage an ongoing health condition or you need a prescription for an illness, you will want to become familiar with your health care plan's drug list. This is a list of covered drugs that are available to BCBSNM members.

Both brand and generic medications are included on the drug list. The drug list has different levels of coverage, which are called "tiers." Generally, if you choose a drug that is a lower tier, your out-of-pocket costs for a prescription drug will be less.

The drug list is not a substitute for the independent medical judgment of your health care provider. The final decision on what prescription drug is appropriate for you is between your health care provider and you.

You can view your drug list here. Be sure to choose the section that describes your plan.

When You Can Request a Coverage Exception

If your medication is not on (or has been removed) from your drug list, you or your prescribing doctor may want to request a coverage exception.

To request this exception, your prescribing provider will need to send us documentation. To begin this process, you or your provider can call the Customer Service number listed on your member ID card for more information.

You or your doctor can also fill out and submit the Prescription Drug Coverage Exception form. You will need to provide us with your doctor's name and contact information as well as the name and, if known, the strength and quantity of the drug being requested.

BCBSNM will let you or your doctor know of the benefit coverage decision within 72 hours of receiving your request. If the coverage request is denied, BCBSNM will let you know why it was denied and may advise you of a covered alternative drug (if applicable). You or your doctor may be able to ask for an expedited review if:

• You take medication for a health condition and failure to get that medication may either pose a risk to your life or health or could keep you from regaining maximum function
• Your current drug therapy uses a non-covered drug

If your review is expedited, BCBSNM will let you or your doctor know of the coverage decision within 24 hours of receiving your request. If the coverage request is denied, BCBSNM will let you know why it was denied and may advise you of a covered alternative drug (if applicable). You can also appeal the benefit determination.  

How to Request Reconsideration of a Drug Coverage Exception Determination

If your coverage request is denied, you may request an appeal through BCBSNM verbally by calling the telephone number on your member ID card. 

If your coverage appeal request is denied, you will be provided information and a form explaining how you can request review by an Independent Review Organization (IRO). To ask for an external review, please complete the External Review form that was included with your denial and submit it to:

Appeals: Blue Cross and Blue Shield of New Mexico
P.O. Box 660717
Dallas, TX 75266-0717
Fax: 1-972-907-1868

You may also contact the Managed Health Care Bureau (MHCB) at the New Mexico Office of Superintendent of Insurance (OSI) for assistance with preparing the written request for a review at:

Office of Superintendent of Insurance - MHCB
1120 Paseo De Peralta
Santa Fe, NM 87501 
1-505-827-3811 or Toll Free at 1-855-427-5674

If you have any questions about requesting a coverage exception, call the Customer Service number listed on your member ID card.

Before you seek care, it is always best to confirm that your provider is in network in order to receive the highest level of your benefits. However, there are times when care you receive from an out-of-network provider may be covered, such as:

• Emergency care. If you experience a medical emergency and visit an out-of-network emergency room, you do not need approval from your plan first. Afterwards, your claim may be reviewed to ensure it meets the criteria for an emergency medical condition. Once approved, your services will be paid in accordance with the terms of your plan.
• Medically necessary services that are unavailable inside your network. If you need services or treatments not covered by independently contracted health care providers or facilities in your plan's network, you can seek approval to go out of network for these services. To learn more, see When Do I Need Benefit Approval for Medical Services? above.

The allowable amount is the maximum amount your plan will reimburse a doctor or hospital for a given service. Providers who are part of your network have agreed to accept the allowable amount as full payment for covered services and will only bill you for any copays, coinsurance or deductibles under your health benefit plan.

However, when you see an out-of-network provider, if he or she charges more than this allowable amount, you may have to pay the difference up to the provider’s full charge. This is known as balance billing. (You will not be balance billed when you see a network provider or when certain emergency care is received.)

If you receive medical care on or after Jan. 1, 2020, you are protected from balance bills in many situations where you don’t have a choice in where to get care. For example, you are protected from balance bills in the following situations:

• You receive emergency care.
• You receive medically necessary services at an in-network facility, but they are performed by an out-of-network provider and you are unable to choose an in-network provider.

You also are protected from balance bills when you receive air ambulance services.

Note: When you receive post-stabilization services after receiving emergency care from an out-of-network hospital or provider, you may be balance billed if you provide written notice and consent.

If you have any additional questions regarding balance bills, please contact us at the number on your BCBSNM member ID Card.

To avoid balance billing charges, use Provider Finder^® to make sure that the provider is in network.

All covered services are subject to contract benefits, limitations and exclusions. Additional information, including links to plan documents, can be found here.  

To help you better understand your health care coverage, we are providing Summary of Benefits and Coverage (SBC) documents for each of our plans. These SBCs describe key features such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions.

Information in these SBCs represents an overview of coverage. It is not a complete list of what is covered or excluded. Information is subject to change.  Log into Blue Access for Members (BAM^SM) to find full terms of coverage for your policy.  The full terms of the policy will govern your benefits, so it is important that you read and understand them.

When you visit a doctor or other health care provider, your provider will usually submit a claim to us on your behalf. However, if the provider fails to do so, you can submit the claim yourself. You are more likely to have to file your own claim if you get care from an out-of-network provider.

How to File a Claim

If you need to file a claim, you can download and print a medical health insurance claim form.  You can also find this form through our Form Finder.  You will find instructions on the form to help guide you.

Once you have filled out this form, mail it to the following address:

Blue Cross and Blue Shield of New Mexico
P.O. Box 660058
Dallas, TX 75266-0058 

If you have any questions, you can also contact us at the Customer Service number listed on your ID card. You can submit a claim up to 12 months from the date of service.

When submitting a claim, it's important to include a copy of the original bill issued by your health care provider. Be sure to make copies for your records as documents sent in with your claim cannot be returned to you. Basic information to have handy when preparing a claim form includes:

• Your provider's name and address
• Date of service
• Type of service
• Dollar amounts charged by doctor or other health care provider for each service
• Patient name
• Member name
• Member identification number (found on your member ID card)

Follow these steps to avoid any delays in processing your claim:

• File your claim right away after receiving medical care. Waiting to file a claim may result in a denial of medical benefits.
• Give as much detail as you can. Including the original bill from your doctor or other health care provider helps. Be sure to make a copy for your records as any documents attached to your claim cannot be returned to you.
• If BCBSNM asks you for more information, please get back to us quickly.
• If signatures are needed, be sure to get the proper signatures before sending in your claim.

Check the Status of a Claim

You can check the status of a claim in one of the following ways:

• Visit the Claims Center in Blue Access for Members^SM.
• Call the Customer Service number listed on your member ID card.

If your claim has been denied, you can file an appeal to have it reviewed again. The appeals information is located with your Explanation of Benefits (EOB) and your insurance policy. For more information about EOBs, see below.

An Explanation of Benefits (EOB) is a document that is usually sent to you when a medical benefits claim is processed by your health care plan. It explains the actions taken on the claim and provides information to help understand the following:

• The fees billed by your doctor or other health care provider
• The date of service which applies to the EOB
• The services and procedures that were covered
• The amount that your plan will pay
• The amount that you may still owe (if you haven't already paid)
• Any reasons for denying payment along with the claims appeal process.

Your EOB Details

Your BCBSNM EOB is normally divided into 3 major sections:

1. Total of Claim(s) features the main financial information about your claims. It includes the total amount billed, benefits approved and what you may owe to the provider. Sometimes one EOB may contain more than one claim.
2. Service Detail for each claim describes each service you or your dependent received, the facility or doctor, the dates and the charges. It shows the savings your BCBSNM benefits plan provides for you from discounts and other reductions. And, you can see any costs that may not be covered.
3. Summary gives you a clear picture for each claim of your deductible, coinsurance, copays, and health spending accounts, if these apply to you.

The EOB statement is an important record of claims for medical services and benefit coverage. Remember to keep your EOBs for future reference, in case questions come up later about your claim or your bill. Keep your EOBs in a safe place with your other important personal documents, such as your medical records.

Understanding Your Explanation of Benefits

Finally, your EOBs are available both as a paper copy and online. To sign up for paperless EOBs, you may do so at any time in your Blue Access for Members^SM account.

Typically, when you receive medical services, your provider will bill your health plan (BCBSNM) before sending a bill to you. BCBSNM then reviews the services you received and determines which services are covered by your plan. Occasionally, claims may be denied after you've received services. If the claim has already been paid, we may seek a refund from the providers and you may be responsible for the cost. This is also known as a retroactive denial and can happen for a variety of reasons, including:

• BCBSNM conducts a medical necessity review and determines that your services did not meet the definition set forth in your benefit plan. For more information, see the When Do I Need Benefit Approval for a Medical Service? section.
• You are no longer covered by your plan or eligible for benefits, or you were not covered at the time that you received medical services.
• You visited an out-of-network provider for non-emergency services and are covered by a plan that does not have out-of-network benefits.
• Another insurer or source should have been billed for your services before or in place of BCBSNM.

Note: This is not a complete list. For more information, please see your benefits booklet.

The following steps may help you to avoid having your claim denied:

• Review your plan documents for additional information here.  
• Verify your benefits by calling Customer Service at the phone number listed on your member ID card.
• Talk to your provider about BCBSNM's medical policy. You and your provider can access our medical policies online. These policies offer information about certain medical services that may have limitations based on published clinical research.

In addition to the above, your claims may be denied if you lose coverage after failing to pay your premium. For more information, see the What Happens if I Miss a Premium Payment? section.

• If a claim is denied, you may be responsible for the cost of the services received. However, you also have the right to submit an appeal. An appeal is a way to have that decision reviewed.
• To get started, follow the directions listed on your Explanation of Benefits (EOB) under Your Right to Appeal section.

You can also refer to your benefit plan materials by logging in to your Blue Access for Members^SM  account. Or, call the customer service number listed on your member ID card to learn more about the appeal process and plan benefits available to you.

If you have a New Mexico Health Insurance Exchange policy, information regarding refunds can be found on beWellnm.com or by calling the Customer Engagement Center at 1-833-862-3935. 

If you bought your plan on bcbsnm.com, you can recover premium payments you have already made to BCBSNM, also known as recoupment of overpayments.

• Through your right to examine the policy. You have 30 days after your policy is issued to review it. If, for any reason, you are not satisfied with your health care benefits, you may return your policy and your member ID card(s) to BCBSNM. This will void your coverage. BCBSNM will refund any premium you have paid, as long as you haven't had a claim paid under this policy before the end of the 30 days.
• If the policyholder passes away. BCBSNM will refund any premiums paid in advance, following the death of a plan's primary policyholder. You can request that the refund is issued to a different payee, including the deceased's estate.
• If you overpaid for your active policy. BCBSNM will refund additional premium payments up until the end of the current month. For example, if you paid your premium in advance for the month of June, you can receive a refund up until the last day in May.
• If you ask to cancel your policy.  After you cancel your policy, BCBSNM will automatically refund any payments you have made for billing periods after your termination date. You do not need to request this refund.
• If you do not pay your premium and your policy is terminated.  After your policy is terminated, BCBSNM will automatically refund any payments you have made for billing periods after your termination date. This would apply if you do not pay your premium on time and do not pay your outstanding notices by the end of grace period. (For more information on grace periods, please see the What Happens if I Miss a Premium Payment? section.) You do not need to request this refund.

For more information and to begin the process to recover premium payments, please call us at the customer service number listed on your member ID card.

If you miss the due date for a premium payment, you have extra time to make that payment. This is known as the "grace period." During this time, your health care coverage will not be cancelled, although you may see some changes in your coverage, as outlined below.

The length of the additional time and the changes depend on whether you have an Exchange plan with an Advanced Premium Tax Credit (tax credit).

For members with a tax credit: If your premium payment is past due, you have up to 3 months to pay your premium and to keep from losing your coverage. While you may get health care during those 3 months, it does not mean all your claims will be covered by your plan.

In particular, if you receive services in the 2nd and 3rd months of the grace period without paying your full premium, your claims will be pended. This means that no payments will be made to your provider until you pay your premium in full. If you do not pay your past-due premiums in full, you will lose your health care coverage. If this happens, your plan will not pay your medical bills and you could be responsible for paying the entire amount of your medical bills for care you received during the 2nd and 3rd months of the grace period.

During the grace period, BCBSNM will:

• Process claims for services received during the 1st month of the grace period and pend and not process claims for covered services received in the 2nd and 3rd months of the grace period. This means that no payments will be made to your provider until you pay your premium in full.
• Notify the Department of Health and Human Services of your non-payment of premium.
• Notify providers that your claims may be denied for services provided during the 2nd and 3rd months of your grace period.

If you get behind on paying your premium, you must pay all past-due premiums before the end of the 3rd month that your payment is late. If the premiums are past due for more than 3 months, your plan coverage will be terminated and your plan will not pay any of your medical bills for services provided during your grace period. If your coverage is terminated, you will not be able to enroll in a new plan until the next open enrollment period unless you qualify for a Special Enrollment Period.

For members without a tax credit: After your premium payments are late, you must get your account current within 31 days of the payment due date. After 31 days, your policy will be cancelled. If you receive health care during this 31-day period, you may be responsible for paying the entire amount of your medical bills. You must pay all of your outstanding premiums to keep your coverage. If your coverage is cancelled, you will not be able to enroll in a new plan until the next open enrollment period unless you qualify for a Special Enrollment Period.

Prescription Drug Benefits and the Grace Period

Missing your premium payment also affects your prescription drug coverage.

For members with a tax credit: During the 1st month of the grace period, you may not see changes to your prescription drug coverage. During the 2nd and 3rd months of the grace period, your plan will not pay for your prescriptions and you will be responsible for the full discounted retail amount of your prescription until your premium is paid in full. Once you pay your premium and that payment is processed, your full prescription benefits will be restored. At this time, you can submit any claims for prescriptions you had filled during the grace period for reimbursement of the difference.

For members without a tax credit: During the grace period, you may not see changes to your prescription drug coverage. However, if you do not pay your premium in full by the end of the 31-day grace period, your coverage will be cancelled. In addition, we will bill you for prescriptions we covered during the grace period.

For specific premium questions, if you bought your plan on the New Mexico Health Insurance Exchange, you would contact beWellNM.com, or call the Customer Engagement Center at 1-833-862-3935.  If you purchased your plan directly with BCBSNM, please call us at the customer service number listed on your member ID card.  

If you have more than one insurance or HMO health plan, the section of your benefit booklet titled "Coordination of Benefits (COB)" will help explain how your claims are paid by each plan. For example, you and your spouse may be covered under each other's health care benefits plans. In this case, your plan is usually the primary plan for your claims. Your spouse's plan is usually primary for his or her claims.

In both cases, the primary plan will pay first. Afterward, the secondary plan may then pay an additional amount toward the claim, depending on its rules.

If you have dependent children covered under both your and your spouse's health care benefits plan, their primary plan will often be determined by your and your spouse's birthdays. The plan of the parent whose birthday (month and day) occurs first in the calendar year will be considered primary.

For more information about COB, refer to your benefit materials or call Customer Service at the number listed on your member ID card.