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Prior Authorization Changes for Some Government Program Members
Act
by Dec 21, 2026
Effective date
Dec 21, 2026
Identified
Oct 31, 2026
Summary
Blue Cross Blue Shield of New Mexico is removing prior authorization requirements for specific service categories (proprietary laboratory analyses, drugs/biologics, molecular pathology, infectious disease testing, radiology, advanced imaging, orthopedic surgery, foot and ankle surgery, plastic/reconstructive surgery, vascular surgery, organ transplant, general surgery, and ophthalmology) for Medicare Advantage members effective December 21, 2026. Additionally, the plan will begin phasing out the 'Recommended Clinical Review' option starting January 1, 2027, with full removal expected by end of 2027 for most commercial members.
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What to do
by Dec 21, 2026 · 4 steps
01Billing team should update prior authorization workflows to REMOVE the requirement for prior auth submissions to BCBSNM for Medicare Advantage members in the following service categories: proprietary laboratory analyses, drugs and biologics, molecular pathology/genetics, infectious disease molecular testing, radiology, advanced imaging, orthopedic surgery, foot and ankle surgery, plastic/reconstructive surgery, vascular surgery, organ transplant, general surgery, and ophthalmology.
02Verify current eligibility and benefits through Availity Essentials or preferred vendor prior to rendering services, as checking eligibility/benefits and obtaining prior authorization is not a guarantee of payment.
03Effective January 1, 2027: Billing and clinical teams should prepare for the phase-out of Recommended Clinical Review options in utilization management processes for commercial members, with complete removal expected by end of 2027.
04Refer to preservice reviews on the BCBSNM website for detailed lists of affected codes and specific changes.
If missed: Failure to follow current prior authorization requirements may result in claim denials and rendering providers may not seek reimbursement from members.
Original notice
Prior Authorization Changes for Some Government Program Members
bcbsnm.com · Always check the source before changing claims.