May 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:

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.

Updates made to the Provider Reference Manual

The BCBSNM Provider Reference Manual  (PRM) has been updated as part of an annual review, effective June 3, 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.

Webinar on Coding for Chronic Kidney Disease

Join us for a webinar, Coding Stages and Treatment for Chronic Kidney Disease. The webinar is free to providers and coding professionals.

Annual Regulatory Survey of BCBSNM Provider Directories

BCBSNM conducts an annual regulatory survey of the BCBSNM Provider Directories to support member access to current and complete provider information. This survey not only makes certain that our directories are accurate for members and potential members, but also that we are compliant with regulatory requirements. The survey will be conducted beginning in July 2023 by phone should take less than 5 minutes to complete. Survey questions are focused on specific directory listings and will be conducted by a vendor partner (ImageNet) who will identify themselves as calling on behalf of BCBSNM. Thank you in advance for taking a few minutes to respond to our questions when we call.

Prior Authorization Codes Updated, Effective July 1, also watch for Medical Oncology Portal Enhancements

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.

New Support Program for Members with Kidney Disease

We’re offering a new support program to certain BCBSNM members who have chronic kidney disease or end-stage kidney disease, or who are at risk for these diseases.

Track Care Visits During and After Pregnancy

Prenatal and postpartum care contributes to the long-term well-being of new mothers and their infants, according to the American College of Obstetricians and Gynecologists. We encourage you to talk with our members about the importance of attending all care visits during and after pregnancy.

See our New Three-day Payment Policy for Outpatient Services Prior to an Inpatient Admission

Effective June 1, 2023, BCBSNM is implementing a new Clinical Payment and Coding Policy — Outpatient Services Prior to an Inpatient Admission CPCP038 in accordance with guidance from the Centers for Medicare & Medicaid Services (CMS). We will apply a three-day rule for certain services provided to members who are outpatients who are then later admitted as inpatients.

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:

Behavioral Health Consultations During Hospitalization Can Improve Outcomes

Coexisting physical and behavioral health conditions can be difficult to manage. Studies have found that people hospitalized for physical health conditions who also have mental illness are more likely to be readmitted than people who don’t have mental illness. Behavioral health consultations during a hospital stay can help our members who have physical and behavioral health conditions.

Pharmacy Program Updates: Quarterly Pharmacy Changes Effective April 1, 2023 — Part 2

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 April 1, 2023 

2022 Medical Record Review

BCBSNM Quality Improvement Department performs an annual medical record review audit to assess whether practitioners/providers meet the minimum New Mexico Administrative Code (NMAC) and BCBSNM medical record documentation standard requirements for members who are serviced under the Blue Cross Community Centennial network.

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.