September 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:

Transition from required Prior Authorization to Recommended Clinical Review Effective Sept. 18, 2023

For fully insured members with health plans underwritten by BCBSNM, prior authorization requirements for outpatient service categories will be removed effective Sept. 18, 2023. Instead of a required prior authorization, providers will have the option of submitting a Recommended Clinical Review, formerly Predetermination.

Reporting On-Demand via Availity^® Essentials is Now Named Provider Claim Summary

Effective Aug. 2, 2023, BCBSNM is changing the name of its long-standing Reporting On-Demand tool to Provider Claim Summary (PCS). The tool is still available in the BCBSNM-branded Payer Spaces section via Availity and allows users to readily view, download, save and/or print Provider Claim Summaries online.

Shared Decision-Making Aids Can Help Guide Care Choices

Shared decision-making is a communications process. It’s a way for providers and patients to make informed health care decisions that align with what matters most to patients.

Claim Editing Changes for Emergency Department Services Coming Nov. 1, 2023

BCBSNM will enhance our claims editing and review process with Cotiviti for emergency department evaluation and management services for our commercial members. These editing enhancements for facility and professional claims will help ensure accurate billing and proper reimbursement.

Submitting Claims for Infertility Services

When completing claims for infertility services rendered to a surrogate or from a donor, please indicate the recipient on the claim form. Coverage for surrogates and donors may vary by plan. Inclusion of the recipient information on submitted claims will help us to expedite the proper processing of claims for these services.

How to indicate recipient: Simply add “surrogate” or “donor” to the comments or notes field on the claim form. For example:

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:

Pharmacy Program Updates: Quarterly Pharmacy Changes Effective Oct. 1, 2023 — Part 1

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 Oct. 1, 2023 

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.

Expiration of the Public Health Emergency

The Centers of Medicare and Medicaid Services (CMS) sent notice that the Public Health Emergency (PHE) expired May 11, 2023. The Human Services Department (HSD) has issued guidance and directives for modification of services and program standards related to the ending of the PHE associated with the 2019 Novel Coronavirus (COVID-19) outbreak. Please visit the HSD website for more information related to expiration of the PHE under the Letter of Direction #98 .

If you have questions, please contact your Provider Representative using the Network Contact List . Also continue to watch News and Updates for future updates.

New Mexico Medicaid Provider Engagement Forum

BCBSNM will host a Medicaid provider engagement forum on Sept. 8. Providers can register to attend in-person or virtually.

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.