Prior Authorization Changes for Some Commercial and Government Program Members

REQUIREMENTS: 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). Update internal documentation and staff training materials. By 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. Specific 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. Assign responsibility to front desk/eligibility verification staff. CONSEQUENCES: Services performed without required prior authorization or that do not meet medical necessity criteria will be denied for payment. Rendering providers may NOT seek reimbursement from members for denied claims due to lack of prior authorization.