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

Staying healthy is easier when you understand the ins and outs of your health care plan. Some types of care and treatment require prior authorization. With prior authorization, your doctors send information to Blue Cross and Blue Shield of New Mexico (BCBSNM) about the care they recommend before you receive it.

Here are examples of when and why your doctor may check in 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
• Our billing process for services
• 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:

• 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.
• 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 cost less at a clinic or outpatient surgical center instead of a hospital.
• 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
• The drug is right for your condition
• Any special rules, such as where the drug can be filled and how much you can get at one time
• Whether a less expensive generic or brand option is available

Prior authorization helps make sure you get the care you need with as little out-of-pocket cost as possible.

When in Doubt, Find Out

Not all procedures or drugs require prior authorization. For a more complete list of procedures that do require it, check your benefit information. Log in to your Blue Access for Members^SM account. Select the My Coverage tab and click on the prior authorization link under My Coverage Benefits. Next, 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, then choose the link for your plan (5-tier or 6-tier drug list).

Originally published 12/16/2019; Revised 2021, 2022, 2023