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Preauthorization

Know What Your Plan Requires

You may need to preauthorize certain covered health services to ensure you avoid unexpected costs. Preauthorization means that you need to get approval from your health insurance before you can have certain health services performed. This is important to know before you get these services, so we can help you avoid higher costs.

Usually, your network provider will take care of this before the service is performed. But it’s best to confirm for yourself. Call 1-800-572-3089 before you get care.

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 1-800-572-3089 for additional information.

List of Services

Predetermination

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

This table includes a list of services which need predetermination.
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.