Prior Authorization / Referral
Some covered services or medications may need approval from Western Sky Community Care, and this is called a Prior Authorization (PA). You do not need a paper referral from Western Sky Community Care to see a provider, but your provider may need to request a prior authorization from Western Sky Community Care for a service to be approved.
The recently passed Prior Authorization Reform Act is helping us make our services even better. This bill took effect January 1, 2022.
Our prior authorization process will see many improvements. We will be clearer with processes. And we will reduce wait times for things like tests or surgeries. You will also see improved fairness with our PA process.
Our current PA process is NCQA certified. It meets many of the new law's standards. However, we see this as a time to continue improving our services.
For clinical criteria, please see the information linked below. To request PA information or receive additional support, please contact us at 1-844-543-8996 (TTY: 711).
Below is a list of services that require prior authorization from Western Sky Community Care before your healthcare provider can proceed with treatment.
Services That Require Prior Authorization Ancillary Services |
|---|
Air ambulance transport (non-emergent fixed wing airplane) |
Durable Medical Equipment (DME) |
Private Duty Nursing |
Adult Day Care |
Home Health Care |
Hospice |
Respite |
Nurse Respite |
Furnished Medical Supplies and DME |
Orthotics/Prosthetics |
Genetic Testing |
Quantitative Urine Drug Screen |
Specialty Pharmaceuticals |
Therapy Services |
Out-of-Network Providers |
All Out-of-Network Providers require Prior Authorization (excluding emergency room services) |
Procedures/Services |
|---|
Potentially cosmetic |
Bariatric surgery |
Transplants |
High tech imaging requests |
High tech imaging administered by NIA, i.e. CT, MRI, PET |
Obstetrical ultrasound Two (2) allowed in nine months; Prior authorization required for additional ultrasound(s), except if rendered by a Perinatologist |
Pain management |
Intensive Outpatient (IOP) |
Partial Hospitalization (PHP) |
Services that are experimental/investigational |
Inpatient Authorization |
|---|
Medical admissions |
Surgical admissions |
All services performed in out-of-network facilities |
Rehabilitation facilities |
Skilled Nursing facilities |
Inpatient Psychiatric (including detox) |
Observation stays exceeding 23 hours require Inpatient Authorization/Concurrent Review |
Outpatient Programs |
All such services determined by New Mexico Medicaid to be medically necessary shall constitute a Western Sky Community Care Covered Service. See the Western Sky Community Care Member Handbook for more information on coverage out-of-network and out of the New Mexico Western Sky Community Care service area.
Do I need a referral to see a specialist?
No, you do not need a referral from your PCP to see a specialist. You do not need a referral for routine vision care, chiropractic services, or mental health/counseling services.