June 2017  

New Preauthorization Requirements through eviCore

In a previous update, Blue Cross and Blue Shield of New Mexico (BCBSNM) communicated the upcoming new preauthorization requirements for Blue Cross Medicare Advantage members.

The Specialty Prior Authorization Program requirement for Blue Cross Medicare Advantage members initially planned to be effective on April 3, 2017, has been delayed. The new target effective date is June 1, 2017.

Please note that the list for services requiring preauthorization beginning June 1, 2017, has been updated to exclude Cardiac Rhythm Implantable Devices (Crid) and Post-Acute Care (PAC).
Both BCBSNM and eviCore will be providing additional information and training opportunities in the coming months on the Provider website at bcbsnm.com/provider and in Blue Review.

You will continue to use iExchange^® for all other services that require a referral and/or preauthorization. Services performed without preauthorization may be denied for payment, and the rendering provider may not seek reimbursement from members.

* eviCore is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of BCBSNM. Physicians, professional providers, facility and ancillary providers who are contracted/affiliated with an IPA/PHO must contact the IPA/PHO for questions and information regarding the preauthorization requirements.

Please note that the fact that a service has been preauthorized is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member's eligibility and the terms of the member's coverage applicable on the date services were rendered. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.