Prior Authorization Changes for Some Commercial and Government Program Members

REQUIREMENT 1 - By October 1, 2026: Billing team must remove prior authorization requirements for behavioral health codes (commercial members only). Update billing system to eliminate prior auth submission rules for these codes. REQUIREMENT 2 - By October 1, 2026: Medicare billing staff must remove prior authorization requirements for oncology, immunology/specialty infusion, and laboratory/molecular diagnostic codes previously reviewed by BCBSNM. Update system to stop generating prior auth requests for these code families. REQUIREMENT 3 - By January 1, 2027: Billing team must update system to remove prior authorization requirements for miscellaneous codes (commercial members only) and add new prior authorization requirements for radiation oncology codes to be submitted to Carelon. REQUIREMENT 4 - By January 1, 2027: Medicare billing staff must add prior authorization requirements for miscellaneous codes and Emerging Technology, Services & Procedures codes, routing to BCBSNM for review. REQUIREMENT 5 - Immediately and ongoing: All billing staff must verify member eligibility and prior authorization requirements through Availity Essentials or preferred vendor BEFORE rendering services, as utilization management vendors have changed. Services without required prior authorization will result in claim denials and providers cannot balance-bill members. CONSEQUENCE: Failure to obtain required prior authorization or submitting to wrong vendor will result in claim denials with no member recourse.