April 4, 2025
We’re changing prior authorization requirements that may apply to some commercial 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 changes from the Centers for Medicaid & Medicare Services. A summary of changes is included below.
These changes are updates to prior authorization requirements for Administrative Services Only accounts and for optional recommended clinical review for fully insured members.
Changes include:
July 1, 2025 − Addition of genetic testing codes to be reviewed by Carelon Medical Management
July 1, 2025 − Replacement of medical oncology codes to be reviewed by Carelon Medical Management
July 1, 2025 − Addition of medical oncology codes to be reviewed by Carelon Medical Management
July 1, 2025 − Removal of specialty drug codes previously reviewed by Blue Cross and Blue Shield of New Mexico
July 1, 2025 − Addition of specialty drug codes to be reviewed by BCBSNM
More information: Refer to preservice reviews for our updated prior authorization code lists. The code changes will be designated with dates of removal or addition.
Important reminder: Always check eligibility and benefits first through Availity® Essentials or your preferred vendor prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.
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 don’t meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.
CPT copyright 2024 American Medical Association. All rights reserved. CPT is a registered trademark of the AMA.
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.
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.
BCBSNM makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.