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Prior Authorization Changes for Some Commercial and Government Program Members
Effective date
Oct 1, 2026
Identified
Oct 1, 2026
Summary
Blue Cross Blue Shield of New Mexico is restructuring prior authorization and clinical review processes across commercial and government plans, effective in two phases: October 1, 2026 (commercial medical oncology drugs) and January 1, 2027 (genetic testing, sleep services, oncology, orthotics, wound care, and DME codes). Multiple utilization management vendors (Carelon, Evicore, Alacura) will handle different service categories. Additionally, 'recommended clinical review' will be phased out entirely by end of 2027 for most commercial members.
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What to do
Action · 13 steps
01REQUIREMENTS:
By October 1, 2026: Billing team must update prior authorization workflows to route medical oncology drug codes to Carelon for commercial members.
02Verify eligibility and prior authorization requirements through Availity Essentials before rendering services.
03By January 1, 2027: Billing team must implement the following changes in billing system and encounter forms:
1. Route genetic testing codes to Carelon (commercial)
2.
04Remove genetic testing codes previously routed to Carelon
3.
05Remove sleep services codes from prior authorization requirements
4.
06Route neurostimulator sleep codes to BCBSNM (transferred from Carelon)
5.
07Route miscellaneous codes from 'recommended clinical review' to BCBSNM for prior authorization
6.
08Route medical oncology therapy codes to Carelon (commercial)
7.
09Route provider-administered drug codes to Carelon (commercial)
8.
10For Medicare plans: Route oncology drugs, orthotics, wound care, and DME codes to BCBSNM
9.
11Update Part B Step Therapy Program as specified in preservice reviews
Before rendering services on all affected codes: Check eligibility and benefits first through Availity Essentials or preferred vendor to confirm prior authorization requirements and applicable utilization management vendor.
12Consequences: Services performed without required prior authorization or that do not meet medical necessity criteria will be denied for payment, and the rendering provider may not seek reimbursement from the member.
13Claims without required prior authorization will not be paid.
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 →We’ll Begin Removing Recommended Clinical Review as an Optional Medical Necessity Review, Effective Jan. 1, 2027HighEffective Jan 1, 2027 · Medical PolicyPrior Authorization Changes for Some Commercial and Government Program MembersHighEffective Oct 1, 2026 · Prior AuthorizationPrior Authorization Changes for Some Commercial MembersMediumEffective Oct 1, 2026 · Prior AuthorizationPrior Authorization Changes for Some Commercial and Government Program MembersHighEffective Aug 1, 2026 · Prior AuthorizationBrowse every BCBS New Mexico change in the policy list