February 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:

FEP^® Annual Medical Record Data Collection for Quality Reporting — HEDIS^®

Blue Cross and Blue Shield Federal Employee Program^® (BCBS FEP) collects performance data using specifications published by the National Committee for Quality Assurance (NCQA) for Healthcare Effectiveness Data and Information Set (HEDIS). To meet this annual quality reporting requirement, BCBS FEP will be collecting medical records using internal resources, beginning February 2023 through the end of April 2023.

Updates made to the Provider Reference Manual

The BCBSNM Provider Reference Manual (PRM) has been updated, effective March 4, 2023.

Changes to Section 15 have been made to comply with the Office of Superintendent of Insurance’s new Provider Grievance Rule at Sections 13.10.16.1 through 14 NMAC (2023).

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

Prior Authorization Codes Updated, Effective April 1

As of April 1, we’re changing prior authorization requirements that may apply for some commercial and Blue Cross Community Centennial^SM members to reflect new, replaced or removed Codes.

Current Procedural Terminology (CPT^®) Codes Updated for Prior Authorization for Medicare and Medicaid programs, April 1

As of April 1, we’re changing prior authorization requirements that may apply for some Medicare members to reflect new, replaced or removed codes.

ClaimsXten^SM Quarterly Update Effective April 17, 2023

BCBSNM will implement its fourth quarter code update for the ClaimsXten auditing tool on or after April 17, 2023.

Supporting Heart Health Equity

Social determinants of health can play a significant role in cardiovascular health, according to the Centers for Disease Control and Prevention (CDC). Social determinants of health are non‑medical factors that influence health outcomes.

Predetermination is now Recommended Clinical Review

Effective Jan. 1, 2023, BCBSNM is changing the name of its longstanding preservice review, previously called predetermination, to recommended clinical review (RCR).

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 policies were updated:

Inflation Reduction Act to Impact Insulin and Vaccine Costs for Medicare Members

Starting Jan. 1, 2023, the Inflation Reduction Act (IRA) of 2022 will affect the costs of insulin and adult vaccines for Medicare members.

Blue Cross Medicare Advantage Dual Care Plus (HMO SNP)^SM 2020 Program Summary

The Blue Cross Medicare Advantage Dual Care Plus (HMO SNP) program started January 1, 2020. It will continue in its current form for a three‑year period. The program serves older adults and people with disabilities.

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 January 27, 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.

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 January 27, 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^SM. 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.