What is prior authorization and how does it work?

Prior authorization is a process employed by health insurance providers, including Blue Cross Blue Shield of New Mexico, to determine if a specific treatment, medication, or service is medically necessary and, therefore, covered under a member's insurance plan. It aims to ensure that patients receive appropriate care while managing costs and resources efficiently. The process generally begins when a healthcare provider requests approval for a particular service or treatment on behalf of the patient. This request is submitted to the insurance company, where it undergoes a review by a team of medical professionals. They assess various factors, including clinical guidelines, the patient's medical history, and the specific details of the proposed service. If the request is approved, the provider is notified, and the patient can proceed with the treatment. However, if the authorization is denied, the provider and patient may receive an explanation regarding the decision and, if appropriate, they may appeal the decision or explore alternative treatment options. It is essential for members to understand that prior authorization does not guarantee coverage; it merely confirms that the proposed services or medications meet the necessary criteria. Members are encouraged to familiarize themselves with their insurance plan details, which often include information on the prior authorization process. More information can be found directly on the current web page associated with Blue Cross Blue Shield of New Mexico.