Encourage Annual Eye Exams for Members with Diabetes

Early detection and treatment can greatly lower the risk of vision loss and eye diseases. See tips to close care gaps and coordinate care.

Watch for Updates to Availity^® Essentials Claim Status Tool

With November’s updates, you’ll experience consistent tool options with multiple payers when verifying real‑time claim status for members.

Take Note of Paid Claims Editing Enhancements for Medicaid and Medicare Advantage

Beginning in February 2026, we’ll enhance our claims editing and review process for some members to ensure services are properly reimbursed.

Review Prior Authorization Changes for Commercial and Government Plans

Effective Jan. 1, 2026, prior authorization requirements for certain commercial and government plans are changing to reflect new, replaced or removed codes.

Reach Out to Members to Close Care Gaps and Support Wellness

With the year coming to a close, remind our members to receive any preventive screenings, follow‑up care or immunizations they may need. We can provide data to help.

Explore Learning Opportunities

We offer free training for providers who participate in our networks. Upcoming sessions include a behavioral health provider webinar on autism spectrum disorder offering continuing education credit. Review options and sign up.

Verify Your Directory Information Every 90 Days

Our members rely on our provider directory for accurate information about your practice. Review and verify your data every 90 days and update it when it changes.

Review Updates on Managing Your Data in Availity Essentials

The Provider Data Management tool is updated with a new look and more uniform workflow for you to quickly update and verify your information with us. See what’s changed.

See Pharmacy Program Quarterly Update – Part 2

Changes were made to our drug lists and utilization management program. Learn about these and other pharmacy program updates.

Take Note of Provider Reference Manual Updates

Our Provider Reference Manual is updated, effective Oct. 13, 2025. Changes to the manual include, but aren’t limited to, the following sections: 10 – Prior Authorization and Recommend Clinical Review and 11 – Utilization, Case, Population Health and Condition Management. Please review it for all changes.

See New Coding Policy on Psychiatry and Psychotherapy Services

Effective Dec. 22, 2025, we’ll implement a new Clinical Payment and Coding Policy, CPCP051 Psychiatry/Psychotherapy Services‑Professional Provider, with billing and coding guidance.

Learn About Updates to Clinical Payment and Coding Policies

We regularly add and modify CPCPs as part of our ongoing policy review. See which policies were updated and when.

Review Active and Pending Medical Policies

Approved new or revised medical policies and their effective dates are usually posted on our website the first and 15th of each month. 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.

See Reimbursement Changes for Out‑of‑Network Residential Treatment Centers

Beginning Jan. 1, 2026, reimbursement rates for Medicaid out‑of‑network RTC providers will be based on a per diem or a statewide average of the rates from the New Mexico Health Care Authority.