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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 the patient will know in advance if the procedure is covered under their group benefit plan. *  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.

Necessary Documents

To begin the review process, your health care provider will need to forward all information requested.

  • Physician letter of medical necessity, which should include:
    • Description on any tissue to be removed
    • Height, weight and diets or programs used for attempted weight loss
  • 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 applicable
    • 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.

Services Requiring Predetermination

The following is a list of services requiring predetermination. Please note that this is not an all-inclusive list. Should you have questions about this list, please contact Blue Cross and Blue Shield of Illinois at 1-800-621-7336 (Bargained), 1-855-439-3641 (Management).

List of services requiring predetermination
  • MRI of the Breast
  • Ostetomies
  • Chelation Therapy
  • Depo
  • Sclerotherapy
  • Breast Reduction
  • Growth Hormone
  • IVIG
  • Blepharoplasty
  • Botox
    		•
  • Blepharoptosis
  • Dental Implants
  • Brow Ptosis Repair
  • Nasal Surgeries
  • Abdomioplasty
  • Gastric Bypass
  • Lipectomy
  • Panniculectomy
  • Brachytherapy
  • Select Behavioral Health Services, including Applied Behavior Analysis
    		•

    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 660603
    Dallas, TX 75266-0603

    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 two to three 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.

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