My Coverage Explained

Health Insurance Terms: What is a predetermination?

A trip to the doctor’s office can sometimes require a dictionary. “Ah, yes, you’ll need a (insert words that may as well be Latin) before you can have that procedure or any medicine.” If your doctor has had this conversation with you before, then you know how confusing it can be. Luckily, using your health insurance  doesn’t have to be confusing.

For example, you may have been told you need a predetermination. You might be thinking, “A pre-what?” A predetermination of benefits is a review by your insurer’s medical staff to decide if they agree that the treatment is right for your health needs. Predeterminations are done before you get care, so that you will know early if it is covered by your health insurance plan. The predetermination of benefits depends on information your doctor sends to Blue Cross and Blue Shield of Illinois’ (BCBSIL) medical staff.

PredeterminationMaybe you’re thinking, “If my doctor tells me I need something, why does it need a second approval? Shouldn’t the doctor’s instruction be enough?” Often, it’s important to have a medical person who knows more about your coverage to review the request. Maybe there will be another option that’s just as successful for you and covered under your plan.  Making sure your treatment is covered will ultimately save you money. Sometimes, your plan may require that the doctor show you have tried other treatments first. For example, if you struggle with your weight, your doctor may tell you that you should have gastric bypass surgery. Your doctor may need to show that you have been on a medical weight loss plan first.

So here’s the breakdown of how predetermination works:

  • The doctor’s office will call BCBSIL to verify your benefits.
  • BCBSIL will decide if predetermination is needed, and let the doctor know.
  • If the doctor’s office learns you need a predetermination, the doctor will send the required details telling BCBSIL’s medical staff telling why you must have the treatment. If you feel like you want to do more, you can also submit a predetermination form  for yourself.
  • The BCBSIL medical staff will consider the request, make a decision, and tell your doctor.

Here are some services that may require a predetermination. But remember, the details can be different for every plan.

  • Botox
  • Breast MRI
  • Breast Reduction
  • Dental Implants
  • Growth Hormone
  • Nasal Surgery

If your predetermination is approved, you can continue with the service or buy the medicine under the benefits covered by your health insurance plan. If your predetermination is denied, you can still have the service or buy the medicine if you want to, but you’d have to pay for all of it by yourself. You can also appeal the decision , which gives you the chance to provide more details to medical review that you think will change the decision.

If you ever have questions about a predetermination or anything else about your coverage, always feel free to look on our website, call us at the number on the back of your ID card, or drop your question in the comment area below! Always remember to keep your personal information private—we have a private message section available if you need to provide specific information about your question.

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