Predetermination: Important Tips

May 8, 2010

Predetermination of Benefits — A voluntary, written request for review of treatment or services; includes services that may be considered experimental, investigational or cosmetic. Predetermination approvals and denials are usually based on provisions in our medical policies. A predetermination of benefits is not a substitute for the precertification process.

  1. Always check benefits before submitting a predetermination. A predetermination is not available for all procedures.
  2. Fax each patient separately. Always place the Predetermination Request Form  on top.
  3. Fill out the entire form. View the Predetermination Request Form online.
  4. Include provider address and fax number.
  5. Provide the contacts name, address and phone number.
  6. Always provide the procedure code and the diagnosis code.
  7. If applicable, provide left, right or bilateral.
  8. Regarding major diagnostic tests, please include the patient's history, physical and any prior testing information.
  9. A predetermination is not available for complete or partial bony impacted teeth. Please check the patient's benefits.
  10. If the procedure is cosmetic in nature, please include original photos or digital color copies that clearly show the affected area of the body. This information must be mailed.

View our Medical Policy .

View 2010 Provider News and Updates