Get Il Bcbs Predetermination Request Form 2020-2025
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How to fill out the IL BCBS Predetermination Request Form online
Filling out the IL BCBS Predetermination Request Form online can seem daunting, but with the right guidance, it becomes a straightforward process. This guide will provide you with clear and supportive instructions to successfully complete the form and submit it for a predetermination request.
Follow the steps to successfully complete the form online.
- Click the ‘Get Form’ button to access the IL BCBS Predetermination Request Form online. This will open the form in your preferred document editor.
- Begin by entering today's date and the scheduled or anticipated service/admission date at the top of the form. Ensure that these dates are correct to prevent any delays.
- In the provider data section, fill in your information as the submitting provider. Include your first name, last name, telephone number, and the details for the ordering physician, making sure to provide their Type 1 NPI.
- Next, complete the rendering provider/facility information. This includes entering the rendering provider's name, Type 2 NPI, and contact details. Be detailed but concise.
- Proceed to the member data section. Input the member identification number, group number, patient’s date of birth, and both the member's and patient’s first and last names accurately.
- Move to the documentation section. Attach any necessary documentation that supports your request, including procedure codes and diagnosis codes. Be sure to check all applicable options for place of treatment and type of documentation.
- Review all entered information for accuracy, including the required fields like contact numbers and procedure codes. Any errors or missing information could delay the process.
- Once confirmed, submit the completed form. Fax the form to the appropriate BCBSTX number provided, or if faxing is not an option, mail it to the address listed at the top of the form.
- Finally, keep a copy of the submitted form and any supporting documents for your records. This ensures that you have all the relevant information accessible in the event of a follow-up.
Start filling out the IL BCBS Predetermination Request Form online today to ensure your request is processed efficiently.
Fill IL BCBS Predetermination Request Form
Recommended Clinical Review (Predetermination) Request Form – Medical and Surgical. It is important to read all instructions before completing this form. BCBSIL is pleased to introduce an electronic predetermination of benefits request process via the Availity Provider Portal using the new Attachments tool. Fax each completed Predetermination Request Form to . If unable to fax, you may mail your request to BCBSIL, PO BOX 805107, Chicago, IL 60680-4112. The document provides instructions for submitting requests for predeterminations of benefits to Blue Cross and Blue Shield of Illinois (BCBSIL). To submit this form, fax each completed Predetermination Request Form to . Submit for medical or behavioral health inpatient or outpatient services. Track authorization cases.
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