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We’ll Begin Removing Recommended Clinical Review as an Optional Medical Necessity Review, Effective Jan. 1, 2027
Act
by Dec 31, 2026
Effective date
Jan 1, 2027
Identified
Sep 17, 2026
Summary
Blue Cross Blue Shield of New Mexico will eliminate 'recommended clinical review' as an optional medical necessity review option for commercial members, effective January 1, 2027. Services that previously used recommended clinical review may now require prior authorization instead. Billing teams must verify eligibility and prior authorization requirements through Availity Essentials before rendering services.
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What to do
by Dec 31, 2026 · 5 steps
01Billing and clinical teams must audit all current workflows that rely on recommended clinical review for commercial members and identify which services will transition to prior authorization requirements.
02Update billing software, encounter forms, and provider communication templates to reflect mandatory prior authorization for affected services.
03Effective January 1, 2027: Implement mandatory eligibility verification through Availity Essentials or preferred vendor for all commercial services that previously used recommended clinical review.
04Train all billing, front desk, and clinical staff on the transition.
05Update internal protocols to require prior authorization submission before service delivery for any service previously covered under recommended clinical review.
If missed: Failure to obtain prior authorization may result in claim denials for commercial members.
Original notice
We’ll Begin Removing Recommended Clinical Review as an Optional Medical Necessity Review, Effective Jan. 1, 2027
bcbsnm.com · Always check the source before changing claims.