Bcbs Predetermination Form PDF Details

If you are like many people, you have health insurance through your employer. While there are many benefits to having health insurance through your job, one downside is that you may not always have control over which doctors you can see. This can be especially frustrating if you need to see a specialist and your insurance company denies coverage for the appointment. If this happens to you, don't worry—you have a few options. One option is to ask your doctor for a predetermination form. A predetermination form is a request for pre-approval of services from your insurance company. This form will let your insurance company know that you require treatment from a specific doctor and will help them determine if they will cover the cost of the appointment. If you are denied

QuestionAnswer
Form NameBcbs Predetermination Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesbcbs florida predetermination form, blue cross blue shield of texas prior authorization form, predetermination bc bs florida, florida blue prior authorization form

Form Preview Example

Predetermination Request Fax Form

Use this form to request:

1.A predetermination of benefits prior to rendering services.

2.An appeal of a previously denied predetermination of benefits.

Please include all required information, such as Provider information, Patient information and specific information for the services in question.

Please note: Inquires received without the member/patient’s group and ID number cannot be completed and may be returned to you to supply this information. It is important that all fields on the form be completed. If all information is not provided, this may cause a delay in the predetermination process.

Fax the completed form to (800) 852-1360

Predetermination requests will only be accepted at the dedicated fax number.

Provider Data:

Date: ___/___/____

 

Name of Provider/Group:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rendering Physician Provider Type:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Billing NPI Number: (If applicable -- Must be 10 digits)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contracting Status:

 

PPO □

Non-Par □

E-mail Address:

 

 

 

 

 

 

Contact First Name:

 

 

 

 

Contact Last Name:

 

 

 

 

 

Telephone Number: (

) -

 

Fax Number: ( ) -

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

State:

Zip

Code:

Member Data:

Member’s Identification Number: (Include alpha prefix)

Group Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

Member’s First Name:

 

 

 

 

Member’s Last Name:

 

 

 

 

 

 

Patient’s First Name:

 

 

 

 

Patient’s Last Name:

Documentation: Attach any documentation that supports or facilitates your review. The following information is required for review. Check all that apply.

Place of treatment:

 

Office □

Outpatient □

Inpatient □

Home □

Evaluation/Health History □

 

 

Office/Therapy Notes □

 

CPT Procedure code(s):

 

 

ICD9 Diagnosis code(s):

 

 

 

 

 

 

 

Other:

 

 

 

 

 

Note: Please do not fax photographs. If additional information is required, i.e. photographs, we will request that you send them by mail.

All other requests, reviews, and standard written inquiries must be mailed to:

Blue Cross and Blue Shield of Illinois

P.O. Box 805107

Chicago, Illinois 60680-4112

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Rev 12/09

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