Encourage Annual Eye Exams and Statin Therapy Adherence for Members With Diabetes

We track Healthcare Effectiveness Data and Information Set (HEDIS^®) measures from the National Committee for Quality Assurance related to diabetes care to identify and close gaps in care.

Updates To Behavioral Health Substance Abuse Criteria for Utilization Management

Effective Jan. 1, 2027, we’ll refer to the American Society of Addiction Medicine’s Criteria 4.0 in our medical necessity reviews of services rendered to adolescents.

Include Required Documentation To Support Preservice Review Process

It’s important to include complete information when requesting a preservice review and medical necessity determination. Requests with complete information reduce delays and avoidable denials.

See Prior Authorization Changes for Some Commercial and Government Program Members

We’ve updated prior authorization requirements for some commercial members and government plans to reflect new, replaced or removed codes.

Reach Out to Members To Close Care Gaps and Support Wellness

With the end of the year approaching, 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 webinars and workshops for providers who participate in our networks. View the schedule and sign up for training sessions, including webinars on coding for chronic obstructive pulmonary disease and coding for chronic kidney disease.

Reminder: Digital Access to Medicare Advantage Prior Authorization Decision Letters

Beginning Dec. 11, 2026, prior authorization approval letters for Medicare Advantage members will no longer be mailed via the U.S. Postal Service. You can view and securely download prior authorization decision letters for these members through the Provider Correspondence Viewer application in Availity^® Essentials.

Keep Your Record ID Active To Prevent Network Termination

If you haven’t filed a claim with your billing or rendering National Provider Identifier and Tax ID number with a date of service within 24 months, we may cancel your corresponding record ID, and you may be terminated from our networks. Learn how to keep your record ID active with us.

Changes Coming to the Medical Drug Benefit Program

Effective Jan. 1, 2027, we will update coverage for specific prescription drugs administered by a health care provider in a clinical setting.

Review Pharmacy Program Quarterly Updates – Part 2

We’ve made changes to our drug lists and utilization management program. Learn about these and other pharmacy program updates.

Learn About Updates to Reimbursement Policies

We regularly add and modify reimbursement policies, formerly known as clinical payment and coding policies, as part of our ongoing policy review. See which policies were updated.

Take Note of Provider Reference Manual Update

Our Commercial Provider Reference Manual   is updated. Changes to the manual include, but aren’t limited to, the following section: 10 – Facility Claims Selection and Retention of Participating Physicians and Other Providers. Please review it for all changes.

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 Updates to Primary Care Quality Improvement Program

The program rewards providers for exceeding benchmarks for certain quality measures. Learn about the changes for 2027.

View Reminders and Quick Tips for Medicaid Authorizations

In April, we launched Medicaid Authorizations, a new application accessible in Availity Essentials. You can use it to check requirements in real time and move directly into the submission process for Medicaid prior authorization requests handled by Blue Cross and Blue Shield of New Mexico.

Health Care Authority Launches New Medicaid Resource

The New Mexico Health Care Authority launched the Medicaid Partner toolkit to provide resources to help providers educate Medicaid members about new federal Medicaid rules.

Talk To Eligible Senior Members About Free Health Program Vive Bien / Live Well

We encourage you to talk with eligible senior members about Vive Bien / Live Well, a free program designed to help adults 65 and older living in New Mexico take an active role in their health and well‑being.