660044 Predeterminationform

User Manual: 660044

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Instructions for Submitting
REQUESTS FOR PREDETERMINATIONS
Predeterminations typically are not required. A predetermination is a voluntary, written request by a provider to determine
if a proposed treatment or service is covered under a patient’s health benet plan. Predetermination approvals and denials
are usually based on our medical policies. View medical policies. The provider and member will be notied when the nal
outcome has been reached.
Urgent care requests include any request for a predetermination with respect to which the application of the time periods
for making non-urgent care determinations;
a. could seriously jeopardize the life or health of the consumer or the ability of the consumer to regain maximum function,
or
b. in the opinion of a physician with knowledge of the consumer’s medical condition, would subject the consumer to severe
pain that cannot be adequately managed without the care or treatment that is the subject of the request.
IMPORTANT PREDETERMINATION REMINDERS
1. Always verify eligibility and benets rst.
2. You must also complete any other pre-service requirements, such as preauthorization, if applicable and required.
3. All applicable elds are required. If all information is not provided, this may cause a delay in the predetermination process.
(Inquiries received without the member/patient’s group number, ID number, and date of birth cannot be completed and
may be returned to you to supply this information.)
4. You MUST submit the predetermination to the Blue Cross and Blue Shield Plan that issues or administers the patient’s
health benet plan.
5. Fax information for each patient separately, using the fax number indicated on the form.
6. Always place the Predetermination Request Form on top of other supporting documentation. Please include any additional
comments if needed with supporting documentation.
7. Do not send in duplicate requests, as this may delay the process.
8. Per Medical Policy, if photos are required for review, the photos should be mailed along with the
Predetermination Request Form and not faxed. Faxed photos are not legible and cannot be used to make a determination.
9. Fax each completed Predetermination Request Form to 888-579-7935.
If unable to fax, you may mail your request to BCBSTX, P.O. Box 660044, Dallas, TX, 75266-0044.
10. For Federal Employee Program members, fax each completed Predetermination Request Form to 888-368-3406.
If unable to fax, you may mail your request to BCBSTX, P.O. Box 660044, Dallas, TX, 75266-0044.
This form does not apply to Blue Cross Medicare Advantage HMOSM and Blue Cross Medicare Advantage PPOSM.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 729617.0815
FOR INTERNAL USE ONLY
PRED
(Work Item Type)
Predetermination Request Form – Medical and Surgical
It is important to read all instructions before completing this form. This form cannot be used for verication of benets or to request an appeal of non-
certication determination.
Please note that the fact that a guideline is available for any given treatment or that a service or treatment has been preauthorized or predetermined for
benets, is not a guarantee of payment. Benets will be determined once a claim is received and will be based upon, among other things, the member’s
eligibility and the terms of the member’s certicate of coverage applicable on the date the service was rendered.
You will receive written notication once a determination has been made.
PROVIDER DATA
Submitter Information
Submitting Provider:
Contact First Name: Contact Last Name:
Telephone Number:
Ordering Physician
Ordering Physician: (Individual – Type 1 NPI)
Ordering Physician First Name: Ordering Physician Last Name:
Contact First Name: Contact Last Name:
Telephone Number: Fax Number:
Street Address:
City: State: Zip:
Rendering Provider/Facility
Rendering Facility/Physician/Provider: (Organization – Type 2 NPI) (Must be 10 digits)
Rendering Physician Provider Type:
Rendering Provider/Facility Name:
Contact First Name: Contact Last Name:
Telephone Number: Fax Number:
Street Address:
City: State: Zip:
MEMBER DATA
Member Identication Number: (Include the 3-digit prex)
Group Number:
Member’s First Name: Member’s Last Name:
Patient’s First Name: Patient’s Last Name:
Patient’s Date of Birth: / /
DOCUMENTATION:
Attach any documentation that supports or facilitates your review. The following information is required for review. Check all that apply.
Place of Treatment: Provider Ofce Outpatient Facility Inpatient Facility Home Ofce Other
Evaluation/Health History Ofce/Therapy Notes
Procedure Code(s): Diagnosis Codes:
Additional Procedure Code(s): Left Right Bilateral N/A
Urgent Non-urgent
Today’s Date: / / Scheduled/Anticipated Service Date: / /

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