Is Your Care Covered? Talk to Your Doctor

Is Your Care Covered? Talk to Your Doctor

Is Your Care Covered? Talk to Your Doctor

This article is intended for members enrolled in an individual health insurance plan.

Some types of health care or treatments may require a pre-service review. That means your doctor will send information to Blue Cross and Blue Shield of New Mexico (BCBSNM) about the care they are recommending before you receive care.

Here are examples of when and why your doctor may check with us.

Before an Appointment

Your doctor may check with us before your appointment to confirm:

  • The doctor or provider is in your network
  • Your coverage is active
  • How to bill for their services
  • That HMO members have a referral from their primary care provider (PCP) to see a specialist
Before a Diagnostic Test or Medical Procedure

Your doctor may check with us before certain tests or other procedures to confirm that:

  • The care meets the “medically necessary” guideline. For example, tests like an MRI or CT scan may not be needed. If another doctor has already had them done, the results on file may be recent enough to use.
  • The care is covered. Not everything a doctor can do is covered by all health plans. Some plans don’t cover weight loss surgery, for example.
  • The care will be provided in your plan’s network. If you see a specialist or go to a hospital that isn’t in your network, you could end up paying a lot more — or even all — of the charges.
  • The care will be provided at the most appropriate location. Some services can be done at a lower cost at a clinic instead of a hospital, for example.
  • The care plan follows any health plan limits, like number of days in the hospital.
When Prescribing Medicine

Your doctor may check with us before prescribing some medicines:

  • To confirm the drug is covered by your plan
  • To make sure the drug is labeled for your condition
  • To see if there are any special rules for your drug, such as where it can be filled and how much you can get at a time
  • To check whether there is a less expensive generic or brand option

Pre-authorizations like these help us make sure you get the care you need with as little out-of-pocket cost to you as possible.

When in Doubt, Find Out

Not all procedures or drugs require pre-service reviews. For a more complete list of procedures that do require pre-service review, check your benefit information by logging in to your Blue Access for MembersSM (BAM)SM account. Select the My Coverage tab and click on the prior authorization link under My Coverage Benefits, then click Referral and Prior Authorization Information.

To check your drug list, see Prescription Drug Lists at bcbsnm.com. Select Prescription Drug Lists for Metallic Individual Plans and then select the link for your type of plan (HMO or non-HMO).

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