Your Guide to Understanding Prior Authorization

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, 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.

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 days.

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.

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.

Learn what’s considered urgent and find more information about prior authorization timing on our Transparency in Coverage page.

If coverage for a health care service or medication is denied, you and your doctor may change your treatment plans or appeal the decision. If you get the service or drug without prior authorization, you will have to pay the costs.

You have the right to appeal the decision. Information about the appeal process is included with the decision notification. You can also find it in your benefits documents.

The prior authorization process is in place to protect you, your doctor and your insurer. It helps make sure the service or medicine requested is safe, appropriate for your needs, cost-efficient and covered by your plan.

During the prior authorization 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 normally refers to health care services that:

• are effective at treating or managing a medical condition or symptom;
• are clinically appropriate in terms of type, frequency, extent, site of service, and duration; 
• follow generally accepted medical standards;
• are not considered experiential or investigational, except those described under your policy; and
• are not primarily for the convenience of you or your provider. 

The easiest way to make sure your prior authorization request is reviewed quickly and accurately is by working with your doctor. Make sure your patient information is up to date. Follow up with your doctor’s office if you have questions. Know if the request was submitted as “urgent” or “non-urgent” to understand the timeline.