Well Child Visits Are Required for Children in State Custody Within 30 Days

Children in state custody must have a well child checkup completed by a primary care provider, school‑based health center, federally qualified health center, rural health clinic or tribal provider within 30 days.

Learn How to Submit Photos to Support Utilization Management Requests

Use our electronic processes to submit photos to support prior authorization and recommended clinical review requests. Secured email and online options are preferred instead of faxing photocopies.

Accurate Category II Codes May Help Identify Gaps in Care

Using the proper Current Procedural Terminology (CPT^®) Category II codes on claims can help streamline your administrative processes and ensure gaps in care are closed. We developed a coding reference for several quality measures that you can access in Availity^® Essentials.

Cultural Awareness Webinars: Earn No‑Cost Continuing Education Credit

We offer a suite of self‑guided courses that provide cultural awareness training and continuing education credit. Webinars include chronic disease management and improving adherence in diverse populations.

Funds to Be Recouped on Some Medicare Advantage Hospital and Ancillary Claims

We recently identified that some Medicare Advantage claims were paid incorrectly to hospitals and ancillary providers. You’ll receive a letter if you have any impacted claims. Learn more about our recoupment process.

Prior Authorization Changes for Government Programs

Effective Jan. 1, 2025, we’re changing prior authorization requirements for Medicare Advantage members to reflect new, replaced or removed codes.

Preferred Drugs to Be Recommended Through Enhanced Prior Authorization

When submitting prior authorization requests for certain drugs, you’ll receive recommendations for comparable preferred drugs, as of Jan. 1, 2025. This process can improve access to more affordable care for our commercial and individual members.

Pharmacy Program Quarterly Update – Part 1

Some changes were made to our drug lists, including revisions, exclusions, dispensing limits and utilization management changes. Learn about these and other pharmacy program updates.

Clinical Payment and Coding Policy Updates

We regularly add and modify our Clinical Payment and Coding Policies as part of our ongoing policy review. Learn about the policies that were updated.

Provider Reference Manuals Updated

Our 2025 provider reference manuals are updated, effective Jan. 1, 2025. The manuals are available online. Please review them for all changes.

• Provider Reference Manual 

• Medicaid Provider Reference Manual 

• Medicare Advantage Provider Reference Manual 

Medical Policy Updates

Approved new or revised medical policies and their effective dates are usually posted on our website the first and 15th of each month under the Standards and Requirements tab. You can view all active and pending policies, as well as draft medical policies, and provide comments on draft policies. These policies may impact your reimbursement and your patients’ benefits.

Nirsevimab Provides RSV Protection for Infants

We encourage you to integrate nirsevimab into your practice this RSV season to help prevent lower respiratory tract disease in infants. Learn about recommendations from the Centers for Disease Control and Prevention for children up to 19 months old.

Annual Medical Record Review Begins in February 2025

Turquoise Care providers may receive medical requests beginning in February 2025. We collect data for Healthcare Effectiveness Data and Information Set (HEDIS^®) measures to help gather information on our members’ care.

Learn About Contracting with Turquoise Care

If you’re interested in becoming a provider of Turquoise Care, call 505‑837‑8800 or 800‑567‑8540. Providers participating in our commercial products are not automatically participating providers in Turquoise Care.

Our Maternal and Infant Health Initiative Is Expanding

We announced a long‑term commitment to improving maternal and infant health in New Mexico with an expansion of Special Beginnings^®.