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Prior Authorization Changes for Some Commercial and Government Program Members
Effective date
Aug 1, 2026
Identified
Jun 30, 2026
Summary
Blue Cross Blue Shield of New Mexico is implementing significant prior authorization requirement changes across multiple service categories (radiology advanced imaging, sleep services, molecular genetic testing, medical oncology, and miscellaneous drug codes) effective October 1, 2026 for commercial and Medicaid Turquoise Care members, and August 1, 2026 for Medicare Advantage members. These changes involve shifting utilization management review responsibilities between BCBSNM, Carelon, and Evicore, and require billing teams to verify current prior authorization requirements before rendering services.
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What to do
Action · 7 steps
01REQUIREMENTS:
By September 1, 2026: Billing team must update prior authorization workflow procedures to reflect all Medicare Advantage changes (Part B Step Therapy Program initiation and code reassignments between BCBSNM and other vendors).
02Update internal documentation and staff training materials.
03By September 15, 2026: Billing team must update all billing software, encounter forms, and eligibility verification protocols to reflect the October 1, 2026 changes for commercial and Medicaid Turquoise Care members.
04Specific updates needed:
- Radiology advanced imaging: Configure system to route to Carelon for prior auth review
- Sleep medicine services: Configure system to route to Carelon for prior auth review
- Molecular genetic testing: Configure system to route to Carelon for prior auth review (note code removal/additions)
- Medical oncology: Configure system to route to Carelon for prior auth review
- Drug codes and miscellaneous drug codes: Configure system to route to BCBSNM for prior auth review
Immediate (ongoing): All clinical staff and providers must verify eligibility and prior authorization requirements through Availity Essentials or preferred vendor BEFORE rendering services for all affected plan types.
05Assign responsibility to front desk/eligibility verification staff.
06CONSEQUENCES: Services performed without required prior authorization or that do not meet medical necessity criteria will be denied for payment.
07Rendering providers may NOT seek reimbursement from members for denied claims due to lack of prior authorization.
Original notice
Prior Authorization Changes for Some Commercial and Government Program Members
bcbsnm.com · Always check the source before changing claims.
Related changes
See all BCBS New Mexico changes →Prior Authorization Changes for Some Commercial and Government Program MembersHighEffective Oct 1, 2026 · Prior AuthorizationPrior Authorization Changes for Some Commercial and Government Program MembersHighEffective Oct 1, 2026 · Prior AuthorizationPrior Authorization Changes for Some Commercial MembersMediumEffective Oct 1, 2026 · Prior AuthorizationUpdate: Prior Authorization Changes for Medicare Advantage Members, Effective Jan. 1, 2026HighEffective Jan 1, 2026 · Prior AuthorizationBrowse every BCBS New Mexico change in the policy list