Authorizations

Is Prior Authorization Required?

You can check to see if behavioral or medical prior authorization is required.

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Prior Authorization or Utilization Management Assistance

505-923-5757

or

1-888-923-5757

.

We may be reached using this number both during and after normal business hours.

Certain specialized services and prescription drugs require a prior authorization or inpatient notification before being rendered to patients and members. Prior authorizations and inpatient notifications ensure that patients are receiving the right amount of medically necessary care in the right setting for the insurance plan for which they're enrolled.

Medical

Prior Authorization Guide Intel Connected Care Prior Authorization Guide Prior Authorization Request Form Referral Form: Care Coordination/Case Management/Disease Management Notice of Medicare Non-coverage Form Notice of Medicare Non-coverage Form (Spanish)Notice of Medicare Non-coverage Presbyterian Dual Plus Form Important Information Regarding Your Hospice Services, Presbyterian Senior Care (HMO) Plans 1, 2 and 3 only

Fax completed Prior Authorization form to Presbyterian at:

Prior Authorization (505) 843-3047
Inpatient Utilization Management (505) 843-3107
Home Health Care (505) 559-1150
UNM Prior Authorization (505) 843-3108

- OR -

Complete and submit Prior Authorization online

Pharmacy

For the most up-to-date formulary drug information access the Provider Formularies page. Formulary drug coverage status and additional restrictions are listed in the plan’s formulary (drug list).

Provider Formularies

Fax completed Prior Authorization forms to Presbyterian Pharmacy Services at (505) 923-5540 or at 1-800-724-6953.

- OR -

Complete and submit Prior Authorization online

Advanced Imaging Ordering Program

Presbyterian uses the Medical Specialty Solutions (MSS) program, managed by Evolent Specialty Services, for prior authorizations of both non-emergent, advanced diagnostic imaging procedures and cardiac-related imaging procedures performed in an outpatient setting. The program is designed to streamline the authorization process, reduce healthcare costs, and improve patient outcomes. The documents below provide additional information about the MSS program. If you have any questions or concerns about the program, please contact your Provider Network Management relationship executive.

View clinical criteria, timelines, and submit a prior authorization request for advanced imaging

Medical Specialty Solutions Frequently Asked Questions (FAQs)Quick Reference Guide Utilization Review Matrix 2024 Utilization Review Matrix Musculoskeletal Surgery (Spine)Cardiac Frequently Asked Questions (FAQs)

Behavioral Health

Prior Authorization Guide Prior Authorization Request Form

Behavioral Health Medical Necessity Criteria (Medicare/Commercial)

Turquoise Care Concurrent Clinical Review Form Turquoise Care Discharge Clinical Notification Form Turquoise Care Initial Clinical Review Form Turquoise Care Retrospective Clinical Review Form Applied Behavior Analysis (ABA) Clinical Review Form: Stage 3 Applied Behavior Analysis (ABA) Specialty Care Clinical Review Form

Fax completed Prior Authorization form to Presbyterian at:

Turquoise Care BH: (505) 843-3019
Medicare/Commercial BH: 1-888-656-4967

- OR -

Complete and submit Prior Authorization online (Medicare/Commercial) Complete and submit Prior Authorization online (Turquoise Care only)

Is Prior Authorization Required?

You can check to see if behavioral or medical prior authorization is required.

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