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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.
To begin the review process, your health care provider will need to forward all information requested:
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 the number on the back of your member ID card.
Physicians can download a Recommended Clinical Review Form, and return form with applicable information to:
Fax each completed Predetermination Request Form to 1-888-579-7935. If unable to fax, you may mail your request to:
Blue Cross and Blue Shield of Texas
P.O. Box 660044
Dallas, TX 75266-0044
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.