June 27, 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.
These changes are updates to prior authorization requirements for Administrative Services Only accounts and for optional recommended clinical review for fully insured members.
For some services and members, prior authorization may be required through Blue Cross and Blue Shield of New Mexico. Utilization management and related services for some commercial members will be reviewed by Carelon Medical Benefits Management.
Here is a summary of changes, effective Oct. 1, 2025:
- Addition of sleep codes to be reviewed by Carelon
- Addition of genetic testing codes to be reviewed by Carelon
- Addition of a musculoskeletal code to be reviewed by Carelon
- Replacement of medical oncology drug codes reviewed by Carelon
- Addition of medical oncology codes to be reviewed by Carelon
- Removal of a drug therapy code previously reviewed by BCBSNM
- Addition of various drug codes to be reviewed by BCBSNM
Refer to the updated prior authorization CPT code lists in preservice reviews. The code changes will be designated with dates of removal or addition.
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 do not 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.
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.
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 third party vendors and the products and services they offer.