Predetermination of Benefits

A predetermination of benefits is a review by medical staff to determine if the service you are requesting is appropriate for your medical needs. Predeterminations are done prior to services so that you will know in advance if the procedure is covered.* The predetermination of benefits is dependent upon information submitted before the services are rendered. Payment is dependent upon the information submitted after the services are rendered.

Blue Cross and Blue Shield of Illinois Customer Service is able to assist you with initiating a predetermination of benefits. Please contact Customer Service at 888-652-4013 for additional information.

List of Services — We highly encourage you to request a predetermination for the following list of services. Please note that this is not an all-inclusive list.

Pet Scan

MRI of the Breast

Chelation Therapy

Sclerotherapy

Growth Hormone

Blepharoplasty

Abdominoplasty

Lipectomy

Brachytherapy

Osteotomy

IVIG

Breast Reduction

Dental Implant

Botox

Panniculectomy

Nasal Surgery


Necessary Documents — In order to begin the review process, your health care provider will need to forward all information requested:

1. Physician letter of medical necessity, which should include:

  • Proposed Current Procedural Terminology (CPT) codes
  • Complete description of any procedure not assigned a CPT code
  • Description of any tissue to be removed including approximate amount of tissue

2. Patient evaluation and office notes, including but not limited to:

  • Health/family history form documenting allergies, risk factors, etc.
  • Chief complaint(s)/symptoms(s) as stated by the patient
  • Office notes for the past year with documentation and history of all prior treatments and therapies and patient response to them; description of treatment modalities/interventions that were not able to reduce pain or have been utilized; presenting symptoms and age of onset, if applicable. Office notes also should include any functional issues, prior treatment, including oral and topical medications, and documentation of degenerative changes.
  • Transport notes
  • Hospital evaluation
  • Procedure code(s), including expected duration of treatments and any proposed rehabilitation plan.
  • Pre-operative photos or X-rays, if requested.
  • Any applicable report(s) such as ER, operative, sleep study, cancer staging, medical regimen, initial evaluation, Doppler study/duplex scan, diagnostic test, cat scan/X-ray, speech evaluation, visual field exam or scope.
  • Progress notes from time of injury and, if applicable, serial X-ray results and documentation of any previous failed fusion type.

Providers — Physicians can download a Predetermination Request Form , and return form with applicable information to:

Blue Cross and Blue Shield of Illinois
P.O. Box 805107
Chicago, IL 60690-1364

Predetermination* requests should be completed in 30 days or less, assuming all necessary information has been received. However, the review may take longer if additional information is requested.

International Information: If translation is needed, time frame is 2-3 weeks

* Quotations of benefits and/or the availability or extent of coverage are not a guarantee of payment. Payment is subject to actual information and charges submitted.