July 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:

Letter of Direction (LOD) #85 — Community Benefit Provider Audits

On October 26, 2022, the New Mexico Human Services Department (HSD) issued Letter of Direction (LOD) #85 ; “Community Benefit Audits” effective January 1, 2023. LOD #85 requires the Centennial Care MCOs to collaboratively audit all current Community Benefit providers participating in the Centennial Care program on an annual basis.

Updates made to the Provider Reference Manual

The BCBSNM Provider Reference Manual  (PRM) has been updated as part of an annual review, effective August 5, 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.

Webinars on Cross-Cultural Care Offer Continuing Education Credit

If you haven’t yet completed our webinars on cross-cultural care, there’s still time to register and earn continuing education credit. We’re pleased to offer these webinars at no cost through Quality Interactions, a separate company that provides cultural awareness training to health care professionals.

Blue Community HMO Network^SM (CNN) — Individual On and Off Exchange Plans

BCBSNM has many HMO health plans that are offered to individuals and families on and off the exchange. These health plans use the Blue Community HMO network and is comprised of providers who and which are contracted with BCBSNM to furnish covered services on an in-network basis to members with individual and family coverage.

New Availity^® Eligibility & Benefits Experience

The Availity Eligibility and Benefits tool has been redesigned based on your provider feedback to make it easier to locate the needed patient information in one consolidated view. The refreshed Eligibility and Benefits entry and response screens both offer you a clearer and more concise workflow, as well as flexible options for adding providers, expandable sections, and other toggle/filtering options.

Provider Access and Availability Survey

Every year, we reach out to a selection of our provider community to find out how your office is doing in meeting our members’ needs for accessibility. This survey is part of New Mexico state regulatory guidelines and necessary for accreditation. This year the survey will be sent by email with access to an online version of the survey for some providers in August. We will also reach out in August, by phone, to any provider who does not complete the email survey.

This survey takes less than 10 minutes and only requires awareness of provider office scheduling and, for Primary Care Providers (PCPs), the after-hours messaging used by your office. The Provider Reference Manual (section 4.2.7 for PCP and 4.3.3 for Specialist and BH Access Standards) outlines the expected appointment availability your provider office has for our BCBSNM members as well as the requirements for PCP offices around after hours messaging to patients.

Please take a moment to review these standards in the Provider Reference Manual , as they have been updated in 2022 to comply with new NM state guidelines. Thank you in advance for making certain your office responds to this important survey.

Member Rights and Responsibilities

As a participating provider, it’s important that you are aware of our members’ rights and responsibilities.

Provider Rights and Responsibilities

As a participating provider in BCBSNM provider networks, you have certain rights and responsibilities that may affect your practice.

ClaimsXten^TM Announces Software Version Upgrade

BCBSNM will perform a system software upgrade for ClaimsXten from version 6.0 to version 7.0.

Key enhancements include a new look and feel for the Clear Claim Connection^TM (C3) tool, with new data fields for greater claim specificity. The ICD code set default will now be ICD-10.

Note: Clinical edit clarifications and related sources will continue to be available.

Refer to our Clear Claim Connection Provider Tools page for more details regarding ClaimsXten, including a user guide, rule descriptions and other details.

More Information: Watch for future updates in our monthly issues of the Blue Review.

Checks of eligibility and/or benefit information are 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 services were rendered.

Catch Up on Routine Vaccines and Well-Child Visits

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.

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:

Prior Authorization Codes Updated, Effective July 1

As of July 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, July 1

As of July 1, we’re changing prior authorization requirements that may apply for some Medicare and Blue Cross Community Centennial members to reflect new, replaced or removed codes.

Blue Cross Medicare Advantage Dual Care Plus (HMO SNP)^SM 2021 Program Summary

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

Medicare Providers May Treat Medicare Advantage Flex and Group Medicare Advantage Open Access PPO Members

If you’re a Medicare provider, you may treat Blue Cross Group Medicare Advantage Open Access (PPO)^SM and Blue Cross Medicare Advantage Flex (PPO)^SM members.

You may treat these members regardless of your contract or network status with Blue Cross and Blue Shield of New Mexico (BCBSNM). That means you don’t need to participate in BCBSNM Medicare Advantage networks or in any other BCBSNM networks to see these members.

The only requirements are that you agree to see the member as a patient, accept Medicare assignment, and will submit claims to BCBSNM or your local Blue Cross and Blue Shield Plan.

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.