[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283806-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283806-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","new-mexico-uniform-prior-authorization-form-submission-information-and-clinical-sections","New Mexico Uniform Prior Authorization Form - Submission Information and Clinical Sections","","New Mexico Uniform Prior Authorization Form collects standardized information needed for Blue Cross and Blue Shield of New Mexico to review prior authorization requests for commercial, Medicaid, and different service categories including physical health, behavioral health, and pharmacy. The form specifies submission channels (electronic and fax), preferred coverage review hours, and includes sections to capture enrollee details, provider ordering/rendering information, requested treatment or procedure characteristics, and diagnosis and coding. It further requests service frequency and quantity, and for prescription drugs gathers dosing, route of administration, clinical rationale, formulary or step-therapy exceptions, and alternate therapy context.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/new-mexico-uniform-prior-authorization-form-submission-information-and-clinical-sections/283806/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/new-mexico-uniform-prior-authorization-form-submission-information-and-clinical-sections/283806.png","ImageObject",442,249,{"name":42,"@type":43},"Aria","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-11-03","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",13,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"How can the prior authorization form be submitted?","Question",{"text":63,"@type":64},"Submit the form electronically via Availity Essentials or Availity, or electronically via CoverMyMeds. Fax submissions are also listed, including specific fax destinations.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What information is required about the enrollee?",{"text":68,"@type":64},"The form requests the enrollee name, date of birth, subscriber/member ID, and full address including city, state, and ZIP code.",{"name":70,"@type":61,"acceptedAnswer":71},"What details are needed for prescription drug prior authorization?",{"text":72,"@type":64},"Prescription sections collect diagnosis name and code, patient height and weight if required, route of administration, provider administering setting, medication strength and dosing schedule, quantity limits, current treatment status, start dates, and clinical rationale including formulary or step-therapy exception reasons.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283806,1790176824,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":22},2336464648322,"https://ap-avatar.wpscdn.com/avatar/2200025388227c56fec?_k=1778556882303663488","PO Box 660058 Dallas, TX 75266-0058  \n[www.bcbsnm.com](www.bcbsnm.com)  \nPhone: 800-835-8699  \nFax: 800-773-1521  \nNew Mexico Uniform Prior Authorization Form  \nSubmission Information  \nFor the following members of  \nBlue Cross and Blue Shield of New Mexico:  \nCommercial members for physical health services  \nCommercial members for behavioral health services  \nCommercial members for pharmacy services  \nMedicaid members  \nfor physical health services  \nMedicaid members  \nfor behavioral health services  \nMedicaid members for pharmacy services  \nSubmit the prior authorization form:  \nElectronically: Availity® Essentials  \nFax: 866-589-8253  \nElectronically: Availity  \nFax: 877-361-7659 or  \n312-946-3737  \nElectronically: CoverMyMeds  \nFax: 877-243-6930  \nElectronically: Availity  \nFax: 505-816-3854  \nElectronically: Availity  \nFax: 888-530-9809  \nElectronically: CoverMyMeds  \nFax: 877-243-6930  \nCoverage review:  \nM-F: 8 a. m.– 5 p. m. MT  \nPhone: 800-325-8334  \nAfter-hours coverage review  \n888-898-0070  \n24-hour coverage review Phone: 888-898-0070  \n24-hour coverage review Phone: 800-544-1378  \nM-F: 8 a. m.– 5 p. m. MT  \nPhone: 877-232-5518  \nAfter-hours coverage review Phone: 877-232-5518  \nM-F: 8 a. m.– 5 p. m. MT  \nPhone: 877-232-5518  \nAfter-hours coverage review Phone: 877-232-5518  \n24-hour coverage review Phone: 866-689-1523  \nAvaility is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM. BCBSNM makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer. CoverMyMeds is a registered trademark of CoverMyMeds LLC, an independent third party vendor that is solely responsible for its products and services. BCBSNM makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors. If you have any questions regarding the products or services they offer, you should contact the vendor(s) directly.  \nBlue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation,  \na Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 490066.0426  \nNew Mexico Uniform Prior Authorization Form  \nTo file electronically, send to: See Cover Sheet  \nTo file via facsimile, send to:  \nSee Cover Sheet  \n1. Priority and Frequency  \nStandard 􀂅 Services scheduled for Urgent/Expedited 􀂅 Provider certifies that applying the standard review timeline  \nthis date: may seriously jeopardize the life or health of the enrollee.  \nFrequency Initial 􀂅 Extension 􀂅 Previous Authorization \\#:  \n2. Enrollee Information  \nEnrollee name: Enrollee date of birth: Subscriber/Member ID \\#:  \nEnrollee street address:  \nCity: State: Zip code:  \n3. Provider Information: Ordering Provider 􀂅 Rendering Provider 􀂅 Both 􀂅  \nPlease note: processing delays may occur if rendering provider does not have appropriate documentation of medical necessity. Ordering provider may need to initiate prior authorization.  \nProvider name: Provider type/specialty: Administrative contact:  \nNPI \\#: DEA \\# if applicable:  \nClinic/facility name: Clinic/pharmacy/facility street address:  \nCity, State, Zip code: Phone number and ext.: Facsimile/Email:  \n4. Requested medical or behavioral health course of treatment/procedure/device information  \n(skip to Section 8 if drug requested)  \nService description:  \nSetting/CMS POS Code Outpatient 􀂅 Inpatient 􀂅 Home 􀂅 Office 􀂅 Other* 􀂅  \n*Please specify if other:  \n5. HCPCS/CPT/CDT/ICD-10 CODES  \nLatest ICD-10 Code HCPCS/CPT/CDT Code Medical Reason  \n6. Frequency/Quantity/Repetition Request  \nDoes this service involve multiple treatments? Yes 􀂅 No 􀂅 If “No,” skip to Section 7.  \nType of service: Name of therapy/agency:  \nUnits/Volume/Visits requested: Frequency/length of time needed:  \n7. Prescription Dru","cbCaiihj4m338mUS","https://ap.wps.com/l/cbCaiihj4m338mUS","pdf",177555,"English","# Submission Information\n## Prior Authorization Request Details\n## Priority and Frequency\n## Enrollee Information\n## Provider Information\n## Requested Treatment or Procedure\n## Diagnosis and Codes\n## Frequency/Quantity/Repetition\n## Prescription Drug Information","[{\"question\":\"How can the prior authorization form be submitted?\",\"answer\":\"Submit the form electronically via Availity Essentials or Availity, or electronically via CoverMyMeds. Fax submissions are also listed, including specific fax destinations.\"},{\"question\":\"What information is required about the enrollee?\",\"answer\":\"The form requests the enrollee name, date of birth, subscriber/member ID, and full address including city, state, and ZIP code.\"},{\"question\":\"What details are needed for prescription drug prior authorization?\",\"answer\":\"Prescription sections collect diagnosis name and code, patient height and weight if required, route of administration, provider administering setting, medication strength and dosing schedule, quantity limits, current treatment status, start dates, and clinical rationale including formulary or step-therapy exception reasons.\"}]","New Mexico Uniform Prior Authorization Form - Submission Information and Clinical Sections | PDF",1789620008]