2020 Blue Cross Medicare AdvantageSM Prior Authorization Updates

Oct. 21, 2019

Beginning Jan.1, 2020, providers will be required to obtain prior authorization (or "prior authorization") through Blue Cross and Blue Shield of New Mexico (BCBSNM), DaVita Medical Group (DMG) or eviCore for certain procedures for Blue Cross Medicare Advantage members as noted below.

Claims for services for which prior authorization is required by BCBSNM and not obtained by Network Providers may be denied for payment and Network Providers may not seek reimbursement from members.

Member eligibility and benefits should be checked prior to every scheduled appointment. Eligibility and benefit quotes include membership status, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. It is strongly recommended that providers ask to see the member's ID card for current information and a photo ID to guard against medical identity theft. When services may not be covered, members should be notified that they may be billed directly.

A referral to an out-of-network provider which is necessary due to possible network inadequacy or for continuity of care must be reviewed by the BCBSNM Utilization Management department or DMG (if the member is attributed to DMG this information will be reflected on the ID card) prior to a BCBSNM member receiving care from the out-of-network provider.

To obtain prior authorization through BCBSNM for the care categories noted below, you may continue to use iExchange®. This online tool is accessible to physicians, professional providers and facilities contracted with BCBSNM. For more information or to set up a new account, refer to the iExchange page in the Provider Tools section of our Provider website.

Our goal is to provide our members with access to quality, cost-effective health care. If you have any questions, please contact your Provider Network Representative.


Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized or predetermined for benefits 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 certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member's ID card.

iExchange is a trademark of Medecision, Inc., a separate company that provides collaborative health care management solutions for payers and providers. BCBSNM makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity and Medecision. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.

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.