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Predetermination

What is predetermination?

Predetermination is a:

  • Voluntary utilization management review
  • Written request for verification of benefits prior to rendering services*

*Note: A request for predetermination does not replace checking eligibility and benefits. See Step 1 below for details.

Who requests predetermination?

Predetermination requests may only be submitted by providers.

Why obtain predetermination?

The predetermination process is a service Blue Cross and Blue Shield of Illinois (BCBSIL) offers so you can submit your claims with confidence that the proposed services are in alignment with BCBSIL Medical Policy and/or medical necessity as specified by the member’s benefit plan. A predetermination may:

  • Be helpful if you’re unsure about coverage or medical necessity criteria
  • Eliminate the need for a post-service review

When and how should predetermination requests be submitted?

In general, there are three steps providers should follow.

Step 1 – Check Eligibility and Benefits

Remember, member benefits and review requirements/recommendations can vary based on service rendered and individual/group policy elections. It’s always important to check eligibility and benefits first for each patient at every visit.

  • Checking eligibility and benefits doesn’t provide a recommendation on when to submit a predetermination request. But it helps you identify prior authorization requirements and utilization management vendors, if applicable.
  • If prior authorization is required for a service/drug, predetermination isn’t necessary.

Step 2 – Decide if You Want to Request Predetermination

If you’ve checked eligibility and benefits and prior authorization isn’t required, your next step is to assess if submitting a predetermination request may be a good idea.

  • You can check BCBSIL Medical Policy to help assess if services may be subject to post-service medical necessity review when the claim is submitted. If so, you may want to consider submitting a predetermination request.
  • Also use our Medical Policy Reference List  to help identify predetermination candidates. This list includes codes/services that are subject to medical necessity review, based on our medical policies. (Note: This is not an exhaustive list of all codes. Codes may change and this list may be updated throughout the year.)

  • Quick tip: Check the Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)  policy, which is one of our Clinical Payment and Coding Policies (CPCPs). Codes listed in the EIU CPCP aren’t covered for most members. (If you have benefit questions, call the number on the member’s BCBSIL ID card.)

Step 3 – Submit Your Predetermination Request

If you’ve decided you’d like to obtain predetermination, there are two ways to submit your request:

  • Online – Use the Availity Attachments tool to quickly submit predetermination of benefits requests to BCBSIL via the Availity Portal. For navigation tips, see our Electronic Predetermination of Benefits User Guide . Electronic options are preferred to help expedite your request.
  • By Fax – If you don’t have online access, you may download, complete and fax the Predetermination Request Form  to BCBSIL, along with necessary supporting documentation. Please note that faxed documents do not enter our system immediately.

What happens next?

A medical necessity review is conducted according to details of the member’s benefit plan and for consistency with BCBSIL Medical Policy and Clinical Payment and Coding Policies, the provider agreement, and other nationally recognized peer reviewed medically necessary criteria/guidelines. You will be notified when a final outcome is reached. Your notification will include instructions on how to proceed if further action is needed.

Exceptions and Reminders

The predetermination process does not apply for government programs (Illinois Medicaid and Medicare Advantage) or any of our commercial HMO members.

Post-service utilization management reviews may include requesting medical records and reviewing claims for consistency with:

  • Medical policies
  • The provider agreement
  • Clinical payment and coding policies
  • Accuracy of payment

A post-service utilization management review occurs after the service occurs. During a post-service utilization management review, BCBSIL reviews clinical documentation to determine whether a service or drug was medically necessary and covered under the member’s benefit plan. BCBSIL may ask you for the information BCBSIL doesn't have.

Checking eligibility and/or benefit information, obtaining prior authorization or the fact that a predetermination of benefits has been issued is not a guarantee of payment. Benefits 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 certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.