Fillable Instructions for Submitting REQUESTS FOR PREDETERMINATIONS (Blue Cross and Blue Shield of Illinois)

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Instructions for Submitting REQUESTS FOR PREDETERMINATIONS (Blue Cross and Blue Shield of Illinois)

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Instructions for Submitting
REQUESTS FOR PREDETERMINATIONS
Predeterminations are not required. A predetermination is a voluntary, written request by a member or a provider to determine if a
proposed treatment or service is covered under a patient’s health benet plan. Predetermination approvals and denials are usually
based on our medical policies. Click here to view BCBSIL medical policies or here to view Federal Employee Program (FEP) medical
policies and your FEP Benet Brochure criteria. The provider and member will be notied when the decision on a predetermination
has been reached.
URGENT Denition is below and if not met the request will be re-classied from urgent to standard priority:
• Waiting could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on
a prudent layperson’s judgment, or
• Waiting could seriously jeopardize the life, health or safety of the member or others, due to the member’s psychological function,
or
• In the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to
adverse health consequences without the care or treatment that is the subject of the request.
IMPORTANT PREDETERMINATION REMINDERS
1. Always conrm eligibility and benets rst.
2. You must also complete any other preservice requirements, such as preauthorization, if applicable and required.
(For example, all inpatient admissions require preauthorization.)
3. All applicable elds are required. All information and documents provided must be legible. If all required or necessary
information is not provided, this may cause a delay in the predetermination process. (Inquiries received without the member/
patient’s group number, ID number, and date of birth cannot be completed and may be returned to you to supply this
information.) Procedure (CPT)/HCPCS codes for requested services along with ICD10 diagnosis codes must be listed on the form.
4. You MUST submit the predetermination to the Blue Cross and Blue Shield Plan that issues or administers the patient’s health
benet plan which may not be the state where you are located.
5. Always place the completed Predetermination Request Form on top of other supporting documents. Do not send in duplicate
requests as this may delay the process.
6. Per Medical Policy, if photos are required for review, please email the photos to photohandling@bcbsil.com. The body of the
email should include the patient’s rst and last name, Group number, Subscriber ID number and the patient’s date of birth.
7. A predetermination decision is not a guarantee of payment. Benets 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 contract or certicate of coverage
applicable on the date services were rendered. Exceptions may apply. Regardless of any benet determination, the nal
decision to proceed with any treatment or service is between the patient and the health care provider.
8. ONLY use this form for requests for predetermination. Do Not Use This Form To: 1) submit a claim for payment or request
payment on a claim; 2) request an appeal; 3) conrm eligibility; 4) verify coverage; 5) request a guarantee of payment; 6) ask
whether a service requires prior authorization; 7) request a referral to an out of network physician, facility or other health care
provider.
9. Submission of documents by Provider as part of the predetermination process does not preclude the Blue Cross and Blue Shield
Plan from seeking additional information or documents from Provider in relation to its review of other requests or matters.
10. Fax each completed Predetermination Request Form to 800-852-1360. If unable to fax, you may mail your request to BCBSIL,
PO BOX 805107, Chicago, IL, 60680-3625.
11. For Federal Employee Program members, fax each completed Predetermination Request Form to 888-368-3406. If unable to fax,
you may mail your request to BCBSIL, PO BOX 805107, Chicago, IL, 60680-3625.
This form does not apply to government programs (Illinois Medicaid and Medicare Advantage) or any of our commercial HMO members.
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 241817.1120
FOR INTERNAL USE ONLY
PRED
(Work Item Type)
PROVIDER DATA
Submitter Information
Submitting Provider:
Contact First Name: Contact Last Name:
Telephone Number:
Ordering Physician
Ordering Physician: (Individual – Type 1 NPI)
Ordering Physician First Name: Ordering Physician Last Name:
Contact First Name: Contact Last Name:
Telephone Number: Fax Number:
Street Address:
City: State: Zip:
Rendering Provider/Facility
Rendering Facility/Physician/Provider: (Organization–Type 2 NPI) (Must be 10 digits)
Rendering Physician Provider Type:
Rendering Provider/Facility Name:
Contact First Name: Contact Last Name:
Telephone Number: Fax Number:
Street Address:
City: State: Zip:
MEMBER DATA
Member Identication Number: (Include the 3-digit prex)
Group Number: Patient’s Date of Birth: / /
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:
Provider Oce
Outpatient Facility Inpatient Facility Home Other
Evaluation/Health History Oce/Therapy Notes
Diagnosis Codes:
Drug Name(s): Dose/Frequency/Duration:
Procedure Code(s)/Units:
Left
Right Bilateral N/A
Additional Procedure Code(s)/Units:
Standard Urgent
Today’s Date: / / Scheduled/Anticipated Service/Admission Date: / /
Predetermination Request Form – Medical and Surgical
It is important to read all instructions before completing this form. This form cannot be used for verication of benets or to request an appeal of non-certication
determination.
URGENT Denition is below and if not met the request will be re-classied from urgent to standard priority:
• Waiting could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment, or
• Waiting could seriously jeopardize the life, health or safety of the member or others, due to the member’s psychological function, or
• In the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without
the care or treatment that is the subject of the request.
You will receive written notication once a determination has been made.
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Instructions for Submitting REQUESTS FOR PREDETERMINATIONS (Blue Cross and Blue Shield of Illinois)

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Completed 24 May 2022

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