June 2023

COVID‑19 Information for Providers

Please check the following Blue Cross and Blue Shield of New Mexico (BCBSNM) resources frequently for updates to important information related to COVID‑19:

PEAQ^SM Provider Performance Insights Coming Soon

PEAQ Provider Performance Insights (PPIs) are coming soon. The PEAQ program evaluates physician performance in a transparent and multidimensional way. PEAQ data informs member steerage and can impact network optimization and employer insights. Reports show how providers compare to peers and include info to improve future performance.

BlueApprovR^SM Expedites Medical Surgical, Pharmacy and Behavioral Health Prior Authorization — Attend a Training

BCBSNM continues to streamline the prior authorization process to reduce your workload with BlueApprovR. This new tool in Availity^® Essentials expedites approvals for some medical and surgical, pharmacy drug and behavioral health services for many of our commercial members.

Coverage for Telemedicine Services when the Public Health Emergency Ends May 11

In response to the COVID-19 pandemic, BCBSNM expanded access to certain covered services through telemedicine, or other remote methods, to ensure members were able to maintain access to care. BCBSNM has elected to not make any changes to its coverage of telemedicine services for its insured members when the COVID-19 Public Health Emergency ends on May 11, 2023. Members will continue to be able to access their medically necessary, covered benefits through providers who are able and willing to deliver services through telemedicine.

What’s covered?
Telemedicine services will be provided consistent with the terms of the member’s benefit plan.

Watch for Future Updates:
We will notify you if we make any changes in the future.

More Information:
Review our telemedicine web page for more information

Updates made to the Provider Reference Manual

The BCBSNM Provider Reference Manual  (PRM) has been updated as part of an annual review, effective July 1, 2023. Changes to the PRM include, but are not limited to, the following sections:

The updated PRM is available on the Provider Reference Manual webpage. BCBSNM reminds providers to review the PRM for all changes.

Earn Continuing Education Credit at a Webinar on Avoiding Inappropriate Antibiotic Use

Join us for a free webinar on preventing antibiotics overuse on June 13, 2023, from 11 a.m. to noon MST. Doctors (M.D.s and D.O.s), physician assistants and nurse practitioners will earn one continuing medical education (CME) credit for attending.

ClaimsXten^TM Quarterly Update Effective August 21, 2023

BCBSNM will implement its second and third quarter code updates for the ClaimsXten auditing tool on or after August 21, 2023.

2023 NM Annual NDC Drug Fee Schedule Impact and Timeline

Effective for dates of service on and after July 1, 2023

BCBSNM reviews our Nation Drug Code (NDC) Fee Schedule on an annual basis. Reimbursement rates for some medications may change because of this review. Effective July 1, 2023, BCBSNM NDC rate changes will go into effect.

To evaluate the changes in your reimbursement that may result from BCBSNM’s updated NDC Fee Schedule, you may receive an interactive copy of the Schedule by submitting a Fee Schedule Request Form  (available at bcbsnm.com/provider) on or after June 1, 2023. The Schedule is confidential and proprietary information and must be maintained as such per your Agreement.

BCBSNM values your participation in our programs and welcomes your input. If you have any questions or concerns, please contact your Network Services Provider Representative .

Helping Our Members Manage Diabetes

Because diabetes symptoms can develop slowly, one in five Americans don’t know they have it. You may play an important role in supporting our members through regular screenings, tests and office visits.

See our New Clinical Payment and Coding Policy for Outpatient Facility Services that Overlap During an Inpatient Stay

Effective July 1, 2023, BCBSNM is implementing a new Clinical Payment and Coding Policy, Outpatient Facility Service(s) Overlapping During an Inpatient Stay CPCP039, in accordance with guidance from the Centers for Medicare & Medicaid Services (CMS).

Clinical Payment and Coding Policy Updates

The Clinical Payment and Coding Policies on our website describe payment rules and methodologies for CPT, HCPCS and ICD-10 coding for claims submitted as covered services. This information is a resource for our payment policies. It is not intended to address all reimbursement-related issues. We regularly add and modify clinical payment and coding policy positions as part of our ongoing policy review process.

The following policy was updated:

Members Can Now Access Network of Pharmacies at Accredited Cystic Fibrosis Treatment Centers

Effective March 1, 2023, Prime Therapeutics’ IntegratedRx^TM network has expanded to include pharmacies located within accredited cystic fibrosis treatment centers.

Pharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2023

Based on the availability of new prescription medications and Prime’s National Pharmacy and Therapeutics Committee’s review of changes in the pharmaceuticals market, some additions or drugs moving to a lower out-of-pocket payment level, revisions (drugs still covered but moved to a higher out-of-pocket payment level) and/or exclusions (drugs no longer covered) were made to the BCBSNM drug lists. Your patient(s) may ask you about therapeutic or lower cost alternatives if their medication is affected by one of these changes.

View the Pharmacy Program Updates effective as of July 1, 2023 

Updates Made to the Blue Cross Medicare Advantage Provider Reference Manual

The Blue Cross Medicare Advantage Provider Reference Manual  (PRM) has been updated as part of an annual review, effective July 1, 2023. Changes to the PRM include, but are not limited to, the following sections:

The updated PRM is available on the Provider Reference Manual webpage. BCBSNM reminds providers to review the PRM for all changes.

Medical Records Reminder for Out-of-Area Medicare Advantage Members

If we need medical records for Blue Cross Group Medicare Advantage (PPO)^SM members, you will receive requests from BCBSNM or our vendor, Change Healthcare, as part of the Blue Cross and Blue Shield National Coordination of Care program. Please respond quickly to our requests, including requests related to risk adjustment gaps and Healthcare Effectiveness Data and Information Set (HEDIS^®) measures.

In addition, you may receive requests from EXL Health for select inpatient, diagnosis-related group claims for any out-of-area Blue Cross Medicare Advantage members.

Updates Made to the Blue Cross Community Centennial Provider Reference Manual

The Blue Cross Community Centennial Provider Reference Manual  has been updated as part of an annual review, effective July 1, 2023. Changes to the PRM include, but are not limited to, the following sections:

The updated PRM is available on the Provider Reference Manual webpage. BCBSNM reminds providers to review the PRM for all changes.

Not Yet Contracted?

Providers who are participating in commercial BCBSNM products are not automatically participating providers in Blue Cross Community Centennial. If you are interested in becoming a Blue Cross Community Centennial provider, please call 505‑837‑8800 or 800‑567‑8540.

Reminder: Update your Enrollment Information

Due to Centennial Care requirements, all enrollment information (changes to demographics, licensure or certification, provider status, etc.) must be updated on the NM Medicaid Provider Web Portal .

BCBSNM Website

It’s important for you to stay informed about news that could affect your practice. BCBSNM offers many ways to stay informed via our website, bcbsnm.com/provider, and our provider newsletter, Blue Review. Signing up is easy.

Medical Policy Updates

Approved new or revised medical policies and their effective dates are usually posted on our website the 1st and 15th of each month. These policies may impact your reimbursement and your patients’ benefits. These policies are located under the Standards & Requirements tab at bcbsnm.com/provider.

Clinical Payment and Coding Policies

BCBSNM has adopted additional clinical payment and coding policies. These policies are based on criteria developed by specialized professional societies, national guidelines (e.g. Milliman Care Guidelines (MCG) and the CMS Provider Reimbursement Manual and are not intended to provide billing or coding advice but to serve as a reference for facilities and providers. These policies are located under the Standards & Requirements tab at bcbsnm.com/provider.

Claims Inquiries

Our Provider Service Unit (PSU) handles all provider inquiries about claims status, eligibility, benefits and claims processing for BCBSNM members. For the BCBSNM BlueCard^® PSU, call 800‑222‑7992. For out‑of‑area claims inquiries, call 888‑349‑3706.

Network Services Contacts and Related Service Areas

Verify Your Directory Details & Look for Reminders

Your directory information must be verified every 90 days under a new federal law. It’s easy and quick to get it done for all health plans in Availity^® , or if you prefer, you can use our Demographic Change Form. If we haven’t received your verification, look for emails and postcards from us with the checkmark symbol . They’re a friendly reminder that it›s time to verify or update.

Member Rights and Responsibilities

BCBSNM policies help address the issues of members participating in decision making regarding their treatment; confidentiality of information; treatment of members with dignity, courtesy and a respect for privacy; and members’ responsibilities in the practitioner‑patient relationship and the health care delivery process.