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Your Guide to Understanding Prior Authorization

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What is prior authorization?

Prior authorization is a process where doctors ask Blue Cross and Blue Shield of New Mexico to approve certain health care services or drugs to be covered by your plan.1 

You’ll sometimes hear prior authorization called preauthorization, pre-certification or prior approval. 

When you need to go through the prior authorization process, we, along with outside vendors2, check the service or drug asked for to find out if it’s a medical necessity and appropriate for your needs. This is part of a larger process called utilization management. Review does not replace the advice of your provider.

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How do I know if I need prior authorization?

If you're fully insured3, look up procedures, prescription medicines and behavioral health service that might require prior authorization. Other plans, like Medicare Advantage plans, may have different prior authorization requirements. It's important you check your plan’s specific details. 

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Medical Procedures

Some medical procedures like surgeries, organ transplants, imaging or therapies often require a prior authorization request.

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Medical or Prescription Drugs

Search medical drugs, like specialty prescriptions or those with specific use guidelines, that may require prior authorization.

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Behavioral Health Services

Prior authorization may be required for some behavioral services like psychological testing or psychiatric care.

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Review BCBSNM's Prior Authorization Code Lists

To find the full list of services and drugs that require prior authorization, click below to download a copy of the spreadsheet. Except as otherwise noted, these prior authorization requirements are effective as of Jan. 1, 2025:

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Prior Authorization

Making Requests Simple

Most of the time, your doctor will take care of prior authorization for you. They’ll most likely submit a request and get approval before they offer your care. But it’s always a good idea to check, especially if your doctor's not in your plan network. If you use an out-of-network doctor, you may need to handle prior authorization. Start by calling the number on your member ID card.  

When you call, we'll need the following information:

  • Your name, subscriber ID number and date of birth
  • Your provider’s name, address and National Provider Identifier (NPI)
  • Information about your medical or behavioral health condition
  • Your provider's proposed treatment plan, including any diagnostic or procedure codes
  • When you'll get care and, if you're being admitted, an estimated length of stay
  • Where you’re being treated

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Check If Your Doctor's In Your Network

Log in to your member account and use our Provider Finder® tool to search for in-network doctors, hospitals and providers.

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Frequently Asked Questions

Common Questions About the Prior Authorization Process

Resources

Helpful Articles for Prior Authorization

1Prior authorization is not a guarantee of benefits or payment. The terms of a member’s plan control the available benefits.

2Carelon Medical Benefits Management (Carelon) is an operating subsidiary of Anthem, Inc., an independent specialty medical benefits management company that provides utilization management services for BCBSNM.

eviCore® is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of Blue Cross and Blue Shield of New Mexico.

3Not sure if you’re fully insured? Check with your HR department or benefits administrator. If you aren’t fully insured, check your benefit booklet to learn your list of services that require prior authorization. If you still have questions, please call the Customer Service number listed on your BCBSNM member ID card.