COVID-19 Information for Providers

Please check the following Blue Cross and Blue Shield of New Mexico resources frequently for updates to important information related to COVID-19.

Changes Coming to Claim Inquiry Resolution — High-Dollar, Pre-Pay Reviews Only

The Claim Inquiry Resolution tool within the Electronic Refund Management portal only accepts inquiry submissions related to High-Dollar, Pre-Pay Review requests for most Host (BlueCard^® out-of-area) claims (Medical Records and/or Itemized Bills). The other inquiry options that were available via CIR have transitioned to the Dispute Claim or Message This Payer features.

Provider Onboarding Process Update

BCBSNM is excited to announce that we are consolidating our provider onboarding process to reduce the time it takes to join BCBSNM networks. Effective Feb. 1, 2024, BCBSNM is implementing parallel credentialing and contracting processes. We will now start the credentialing process (subject to complete CAQH credentialing application) at the same time the contract is sent to the provider to sign.

This change supports an improved provider onboarding experience with BCBSNM. Please visit our website for additional information on how to join our Provider Network.

Blue Cross and Blue Shield Federal Employee Program^® HEDIS^® Records: Collecting February through April 2024

Providers who care for our FEP^® members may receive medical record requests from BCBSNM from February through April 2024. We collect data for Healthcare Effectiveness Data and Information Set measures to help monitor FEP members’ care.

Join Our Quality Improvement Committee: Provider Opportunity at BCBSNM

BCBSNM is excited to announce an opportunity for any contracted network providers who are interested in a consultative role as a member of our Quality Improvement Committee. BCBSNM aims to establish a QIC that is representative of the diverse populations covered by BCBSNM and believes that your expertise and insights would be invaluable in achieving these goals while improving member outcomes and member satisfaction.

2023 Annual HEDIS Medical Record Review Begins February 2024

BCBSNM collects healthcare effectiveness data annually through medical record chart review for reporting to the National Committee for Quality Assurance and the U.S. Department of Health and Human Services for the Quality Rating System for services provided in the previous calendar year (2023).

Prior Authorization Updates

We’re changing prior authorization requirements that may apply for some commercial members to reflect new, replaced or removed codes.

ClaimsXten^TM Quarterly Update Effective April 15, 2024

BCBSNM will implement its first quarter code updates for the ClaimsXten auditing tool on or after April 15, 2024.

Coding Webinars: Major Depressive Disorder and Annual Wellness Visits

Join our Coding Compliance team for half-hour webinars on coding and guidelines. The webinars include information from the Official ICD-10-CM Coding Guidelines, American Hospital Association Coding Clinic and Centers for Medicare & Medicaid Services.

Utilization Management: How to Avoid Delays and Denied Claims

Our utilization management program helps ensure our members get the right care, at the right time, in the right setting. Our preservice review process, including prior authorization or optional recommended clinical reviews use evidence-based clinical standards of care to help determine whether a benefit may be covered under the member’s health plan.

Managing Antidepressant Medication

Managing patients’ antidepressant medication can help increase compliance and improve outcomes, according to the National Committee for Quality Assurance.

Supporting Healthy Hearts

To monitor our members’ care, we track data from the quality measures Controlling High Blood Pressure and Statin Therapy for Patients with Cardiovascular Disease.

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:

Appropriate Use of Opioids Program to be Retired January 2024

The Appropriate Use of Opioids program was retired effective Jan. 1, 2024. However, BCBSNM will continue to promote safe and effective use of prescription opioids through an approach that more closely aligns with the Center for Disease Control’s 2022 Guidelines for Prescribing Opioids for Pain, which emphasize flexibility and individualized care.

Pharmacy Program Quarterly Update Changes Effective Jan. 1, 2024 — 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 Jan. 1, 2024

Prior Authorization Updates for Medicare

We’re changing prior authorization requirements that may apply for some Medicare members to reflect new, replaced or removed codes.

Centers for Medicare and Medicaid Services guidelines for Availability and Access Standards to Care for Medicare Advantage Members

The Centers for Medicare and Medicaid Services’ revised guidelines for appointment availability and access should be followed to ensure timely access to medical care for Medicare Advantage members.

BCBSNM New Process Regarding Legal Responsible Individuals as Caregivers

Consistent with Letter of Direction #108 from the New Mexico Human Services Department, effective Feb. 1, 2024, BCBSNM has implemented a new process for personal care agencies that need to hire a legal responsible individual to serve as a caregiver.

New Mexico Kids Matter Receives Grant from BCBSNM to Support Teens in Foster Care

New Mexico Kids Matter announced it recently received a $25,000 grant from BCBSNM’s Blue Impact^SM initiative. The grant will support New Mexico Kids Matter’s Successful Transitions and Adulthood Readiness program, which provides services to prepare and support teen and aging-out foster youth as they transition to adulthood and independent living.