Utilization Management for Fully Insured Plans

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. This can include a review before or after you get care.

• Pre-Service Reviews:
  Prior Authorization (required)
  Recommended Clinical Review (optional)
• Post-Service Review

We use evidence-based clinical standards of care to ensure you get the health care you need.

Prior Authorization

What is Prior Authorization?

Some medical treatment requires approval from Blue Cross and Blue Shield of New Mexico before you get care. This is called prior authorization, preauthorization or prior approval. BCBSNM covers certain services for inpatient, outpatient and home health care. We also cover certain prescription drugs.

BCBSNM will confirm what is covered by your plan. We will check to see if the treatment is medically necessary. If you do not get approval for the treatment, the costs will not be covered (paid) by BCBSNM. You and your provider can still decide to get the treatment, but you may have to pay for it.

Do You Need Prior Authorization?

Need to review a full list of services and drugs that require approval? Download the list below.

• Summary of Medical/Surgical and Behavioral Health Services, and Specialty Pharmacy Drugs that Require Prior Authorization for Fully Insured Members

Who Requests Prior Authorization?

If you go to a provider in your health plan network, they usually take care of this before they perform a service. But it’s always a good idea to check if your provider has received approval from BCBSNM.

If your provider is not in health plan network, you will need to get prior authorization from BCBSNM. If you don’t, we may not cover the cost. This means you may have to pay the bills. To find out if your provider is in network, check our find care tool.

You or your provider can ask to renew a prior authorization up to 60 days before it expires.

BCBSNM contracts with outside vendors such as Carelon Medical Benefits Management® (Carelon) for certain prior authorization services.

How You Can Request Prior Authorization

• Call BCBSNM:
  Check with us to find out if your provider got approval before you get treatment. To do so, you can call the number on your BCBSNM member ID card.
• Use the Request Form:
  If your health care provider has not requested approval, you can request it. Print this prior authorization request form. Give it to your provider to complete and return to BCBSNM. You can also submit the form yourself. Call us if you need help to complete the process.

What Happens During the Prior Authorization Process?

BCBSNM will review the service or drug. They will check to see if it’s medically necessary and will meet your needs. This review does not replace the advice of your provider.

To complete a request, we will need:

• Your name, subscriber ID number and date of birth
• Your provider’s name, address and National Provider Identifier (NPI)
• Your medical or behavioral health condition
• The proposed treatment plan, along with any diagnostic or procedure codes (your provider can help you with these)
• The date you’ll get service and the estimated length of stay (if you will be admitted)
• Where you will get the service or drug

Recommended Clinical Review

What is Recommended Clinical Review?

• This is an optional review that is done before you get care
• It is used to determine if a service is medically necessary
• Use this review to find out if your plan will cover a service
• Some services that don’t require prior authorization may be reviewed for medical necessity before a claim is paid
• Work with your provider to submit a request for recommended clinical review

Who Requests Recommended Clinical Review?

Only a provider can submit a request for this type of review.

To find out if you can get this review for a certain service, check the list below. BCBSNM updates the list when a service is added or removed. 

• Recommended Clinical Review List for Fully Insured Members

If you have questions, call customer service at the number on your member ID card.

Recommended clinical review is not a guarantee of benefits. Available benefits are subject to eligibility and the other terms, conditions, limitations, and exclusions as found in your health plan benefit booklet. This review does not apply to members with Medicaid or Medicare plans.

Post-Service Utilization Management Review

This review happens after you get treatment. During this review, we check to see if a service or drug was medically necessary and covered under your health plan. We may ask your provider for more information.

We may also conduct this review if you or your provider did not get a required prior authorization before you got treatment.

Carelon 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.

Not sure if you’re fully insured? If you are enrolled in an Exchange plan (through BeWellnm^®), you are covered by a fully insured individual plan. If you are enrolled in a group plan through your employer, check with your HR department or benefits administrator. They can tell you if you are part of a fully insured group plan. 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. If you still have questions, call the customer service number listed on your BCBSNM member ID card. Find out if you have a fully insured plan.