Get Predetermination Form - Bcbstx - Bcbstx

This guide provides clear instructions on how to complete the Predetermination Form for BCBSTX online. By following these steps, you can ensure that your request for coverage is submitted accurately and efficiently.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred format for editing.
2. Complete all fields within the form. Ensure that you provide accurate information regarding member and patient data, including Identification Number, Group Number, and names. Be attentive to input the anticipated date of service and the patient’s date of birth.
3. List the procedure codes and diagnostic codes. Make sure to place the primary code first for clarity.
4. Indicate which side the services will be rendered by checking either Left, Right, or Bilateral. Also, select the type of services rendered, such as Provider Office, Outpatient Facility, Inpatient Facility, or Other.
5. In the provided space, you can include any additional information regarding the predetermination request that may assist with the review process.
6. Fill out the Provider Data section, including the National Provider Identifier (NPI), today's date, provider's name, address, and contact information (phone and fax numbers).
7. Ensure all fields are complete and double-check for accuracy. Compile any necessary medical documentation that supports the request.
8. Place the completed form on top of the relevant medical documentation and prepare it for submission.
9. Submit the package in a sealed envelope labeled 'REQUEST FOR PREDETERMINATION' to the appropriate mailing address outlined on the form.
10. If applicable, check the appropriate box for critical services and ensure any required additional documentation is included.
11. After submission, you can save changes, download, print, or share the form as needed.

Take the next step and complete your Predetermination Form online today.