Updates and Reminders: Submit Predetermination of Benefits Submission via Availity^®

October 8, 2020

On July 30, 2020, Blue Cross and Blue Shield of New Mexico (BCBSNM) implemented an electronic predetermination of benefits submission process via Availity’s Attachments tool. Updates were recently made to the Attachments tool to better assist you with submitting your requests online to BCBSNM.

Updates to Online Availity Submission Process

• On-screen messaging has been added in the Patient Information section to ensure the patient’s first and last names match exactly as they appear on the eligibility and benefit response to prevent the predetermination request from being rejected. Refer to the Availity Eligibility and Benefits User Guide  for assistance with verifying patient information online.
• The Service From and To date fields have been removed as they are not required for submission.

Make sure you use Availity’s Attachments Dashboard to confirm the online predetermination of benefits submission was accepted or rejected by BCBSNM. For navigational assistance with this tool, refer to the Electronic Predetermination Request User Guide located in the Provider Tools section of our website.

Reminders

• A predetermination of benefits is a voluntary request for written verification of benefits prior to rendering services. BCBSNM recommends submitting a predetermination of benefits request if the service may be considered experimental, investigational, or unproven, as specified within the BCBSNM Medical Policy .
• Per the Medical Policy, if photos and/or x-rays are required for review, please email to Photo Handling. The body of the email should include the patient’s first name and last name, Group number, Subscriber ID and date of birth.
• Urgent care requests include any request for a predetermination with respect to which the application of the time periods for making non-urgent care determinations:
  • could seriously jeopardize the life or health of the member or the ability of the member to regain maximum function,
    or
  • in the opinion of a physician with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.
• If you don’t have online access, you may continue to fax and/or mail predetermination of benefit requests along with a completed Predetermination Request Form and pertinent medical documentation.

For More Information

If you need further assistance or customized training, contact our Provider Education Consultants.

The information in this notice does not apply to requests for Medicare Advantage members.

^{Please note that the fact that a guideline is available for any given treatment or that a service or treatment has been predetermined for benefits, is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date the service was rendered.}

^{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 any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.}