Do you need a Predetermination of Benefits?

Monday, December 21, 2020

Patient explaining issues to doctor using tablet

Thinking about a surgery, test or other medical procedure? Be sure you and your provider check your benefits first! In addition to being covered under your Plan, all services must be medically necessary and considered standard medical care before TeamCare can consider payment.

Did you know that TeamCare recommends (and in some cases, requires) a predetermination of benefits (PDB)? This is a request your provider submits to make sure that the procedure, service or medical item meets these requirements.

PDBs should be submitted for services such as vein surgeries as well as anything that just might be considered a cosmetic procedure. Examples of other procedures include genetic testing and some durable medical equipment. A full list of recommended and required PDBs can be found under the Providers section of Forms & Documents.

Time is needed to review a request, so you may want to hold off scheduling your procedure until your provider receives a determination. Your provider should submit this request at least 15 business days prior to the service date.

Your provider can log on to, and complete the form online. No need to print and fax or mail; they can just click “submit” and be on their way. Medical procedures can be stressful enough—take away some of the worry by getting necessary approvals up front!