Get Predetermination Request Form - Blue Cross Blue Shield Of Oklahoma - Bcbsok

Filling out the Predetermination Request Form is an important step for Blue Cross Blue Shield of Oklahoma members seeking prior authorization for specific medical services. This guide provides a clear, step-by-step approach to completing the form efficiently and accurately.

Follow the steps to complete your predetermination request form online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Enter the member's identification number, including the three-digit prefix, and group number in the respective fields. Ensure accuracy to facilitate the processing of your request.
3. Provide the member’s and patient’s names in the designated space. Include the anticipated date of service and the patient’s date of birth to keep relevant details organized.
4. List the procedure codes and diagnostic codes. It is important to list the primary codes first to provide clarity regarding the services being requested.
5. Indicate the side of the body relevant to the procedure by checking the appropriate box: Left, Right, or Bilateral.
6. Select the place of treatment by checking one of the options provided: Provider Office, Outpatient Facility, Inpatient Facility, or Other. Make sure to choose the correct option based on your anticipated service.
7. Use the space provided to include any additional information related to the predetermination request. This could help in clarifying your request further.
8. For the provider data section, enter the National Provider Identifier (NPI) number(s), today’s date, provider name, address, contact person, and both phone and fax numbers.
9. Review all entries for accuracy to minimize delays in processing. Once finalized, you can save changes, download, print, or share the completed form as needed.

Complete the Predetermination Request Form online today to ensure timely processing of your request.