See Changes to Prior Authorization for Medicare Advantage

Effective Jan. 1, 2026, we’ll review prior authorization requests for certain care categories that previously were reviewed by EviCore healthcare. Learn what’s changing.

BlueApprovR^SM To Accept Concurrent Reviews and Extensions for Behavioral Health Services

We’ll soon expand the capabilities of BlueApprovR, our utilization management tool integrated with Availity^® Essentials, to further expedite approvals for behavioral health services. Learn how to attend a training.

See Changes to Coverage for Breast Cancer Screening

We’re updating coverage for certain commercial members to align with federal guidance, effective Jan. 1, 2026.

Enhanced Diagnosis Claim Edits To Follow CMS Guidelines

Effective March 1, 2026, we’ll enhance our claims editing process for many commercial members to help ensure accurate coding and proper reimbursement of services.

Use Proper Coding for Evaluation and Management Services, Modifiers and Oncology Drugs and Services

Effective March 1, 2026, we’ll enhance our claims editing and review process for Medicare and Medicaid claims to monitor the proper use of evaluation and management coding, oncology drugs and services coding, and Modifiers 25 and 59.

Follow‑Up Care Is Recommended for Children Prescribed ADHD Medication

Attention‑deficit/hyperactivity disorder is one of the most common behavioral health disorders affecting children. To support quality care, we gather data on follow‑up visits for children using ADHD medication.

Explore Learning Opportunities

We offer free training for providers who participate in our networks. Review and sign up for sessions.

Medicare Providers May Treat Members of Blue Cross Group Medicare Advantage Open Access (PPO)^SM

This open access, national PPO plan is for retirees of employer groups. If you’re a Medicare provider, you may treat these members even if you don’t participate in our Medicare Advantage or other networks.

Provide Medical Records To Support Quality Care

You may receive requests in 2026 for our members’ medical records. We collect data for Healthcare Effectiveness Data and Information Set (HEDIS^®) measures to track quality of care. Learn how you can help by promptly providing complete records for these members:

• Federal Employee Program^®

• Medicaid

• Medicare Advantage

Review Changes to Our Annual National Drug Code Fee Schedule, Impact and Timeline

We review our NDC Fee Schedule on an annual and periodic basis. Reimbursement rates for some medications may change because of this review.

Specialty Pharmacy Network Expands for Some Commercial Members

We’ve engaged with Prime Therapeutics LLC to launch Pharmacy Match, a program that expands the specialty pharmacy network and matches members with qualified specialty and complex care pharmacies.

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.

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.

New Mexico Senate Bill 249 Requires BCBSNM to Reimburse Contracted Medicaid Health Care Providers for Certain Gross Receipts Taxes

Effective Jan. 1, 2026, New Mexico Senate Bill 249 will require Blue Cross and Blue Shield of New Mexico to reimburse contracted Medicaid health care providers for all applicable gross receipts taxes that the provider is required to pay for contracted health care services furnished to BCBSNM’s Medicaid members.

See Our New and Updated EPSDT Resources

Our new well‑child visit resource and updated Clinical Practice and Billing Guideline for Early and Periodic Screening, Diagnostic and Treatment services emphasize preventive health and uniform delivery for improved health outcomes.