Utilization management is at the heart of how you access the right care, at the right place and at the right time. It is a practice that looks at the use of medical care to make sure a service is appropriate. We use evidence-based clinical standards to ensure you get the health care you need.
There are reviews that your doctor can arrange with Blue Cross and Blue Shield of New Mexico before you get care. These reviews help figure out if a service is medically necessary. They also let you know if your health plan will cover it.
Choose a plan type below to learn more:
Fully Insured Health Plans*
Not sure if you’re fully insured?
- Are you enrolled in an Exchange plan with the state of New Mexico (through BeWellnm®)? You are covered by a fully insured individual plan.
- Are you enrolled in a group plan through your employer? If you are not sure if your plan is fully insured or self-funded, check with your HR department or benefits administrator.
- With a fully insured plan, an individual or an employer pays a fixed premium to have an insurance company handle all aspects of the plan. The insurance company covers the cost of your health care.
Here are ways to find out if you are covered by a fully insured plan:
- If you have a group plan, check with your HR department or benefits administrator. Ask them if you have a fully insured plan.
- Look at the back of your BCBSNM member ID card. Fully insured plans have this text on the back of the ID card: “BlueCross BlueShield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an independent Licensee of BlueCross BlueShield Association.”
- Call the customer service number listed on your BCBSNM member ID card.
Administrative Services Only (ASO) Health Plans**
Not sure if you’re part of an ASO group plan?
- An ASO plan is also known as a self-funded or self-insured group plan. This is a type of plan where an employer funds its own insurance plan for their employees and pays claims for their employees’ health care. The employer hires an insurance company to handle the administrative tasks (e.g., process claims).
Here are ways to find out if you are covered by an ASO plan:
- Check with your HR department or benefits administrator. Ask them if you have an ASO plan.
- Look at the back of your BCBSNM member ID card. ASO plans have this text on the back of the ID card: “BlueCross BlueShield of New Mexico, an independent Licensee of BlueCross BlueShield Association, provides claims processing only and assumes no financial risk for claims.” Only ASO plans have this on the back of the ID card.
- Call the customer service number listed on your BCBSNM member ID card.
New Mexico Student Health Plans are also ASO plans.
Summary and Code Lists: Use the links below to review the full list of services and drugs that require prior authorization, click below to download a copy of the spreadsheet.
