Predetermination of Benefits List

February 11, 2021

A predetermination of benefits is a voluntary request for written verification of benefits before rendering services. BCBSTX recommends submitting a predetermination of benefits request if the service may be considered experimental, investigational or unproven, as specified in BCBSTX Medical Policy.

To further assist providers in determining whether to submit a predetermination of benefits request, Blue Cross and Blue Shield of Texas (BCBSTX) has added a list of codes where predetermination may be available and is recommended. This list may be updated monthly. Providers are encouraged to check the list regularly for updates, located on the Predetermination of Benefits Request page of the provider website.

As a reminder, providers can submit a predetermination of benefits electronically using Availity's Attachments tool. If you don't have online access, you may fax and/or mail predetermination of benefit requests along with a completed Predetermination Request Form and pertinent medical documentation.

Please note that whether a guideline is available for any given treatment or a service or treatment has been predetermined for benefits, is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member's eligibility and the terms of the member's certificate of coverage applicable on the date the service was rendered.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.