Predetermination of Benefits Requests

What is a Predetermination

Predetermination of Benefits are:

  • Voluntary utilization management reviews
  • Not necessary for services and drugs on the prior authorization list
  • May be used if you are not sure about coverage or whether we may not consider it medically necessary
  • Written requests for verification of benefits before rendering services (in addition to checking eligibility and benefits through Availity or your preferred vendor)

For your convenience, refer to the below list of procedure codes where predetermination may be available and is recommended.

Predetermination Procedure Code List* Excel Document.

Submitting Predetermination Requests

  • Online using the Availity Attachments application:
    1. Log in to Availity Learn more about third-party links
    2. Select Claims & Payments from the navigation menu
    3. Select Attachments – New
    4. Within the tool, select Send Attachment then Predetermination Attachment
    5. Download and complete the Predetermination Request Form
    6. Complete the required data elements
    7. Upload the completed form and attach supporting documentation
    8. Select Send Attachment(s)
  • Fax or Mail:
    Complete the Predetermination Request Form PDF Document and fax to BCBSTX using the appropriate fax number listed on the form or mail to P.O. Box 660044, Dallas, TX 75266-0044.
    The form also may be used to request review of a previously denied Predetermination of Benefits

You will be notified when an outcome has been reached

*The attached list is for reference only and are not intended to be a substitute for checking benefits or Blue Cross and Blue Shield of Texas' (BCBSTX) medical policies. This list applies only to members who have health insurance through a BCBSTX Plan or who are covered by a group plan administered by BCBSTX. If your patient is covered under a different Blue Cross and Blue Shield Plan, please refer to the Medical Policies of that Plan.

Predetermination of Benefits does not apply to requests for Texas Medicaid or Medicare Advantage members.
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 BCBSTX. BCBSTX 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.