Medical Predetermination of Benefits for Providers
Do you need to submit a request for Medical Predetermination of Benefits?
A medical predetermination is a written request by a Provider to see if a proposed treatment or service is covered under a patient’s TeamCare medical plan. Predetermination approvals and denials are based on medical necessity and the network’s medical policies — in accordance with their Plan Document. The Provider and Member will be notified when the final outcome has been reached.
We require a preauthorization/predetermination through the Member's Network (do not send these to TeamCare) for the following procedures:
- ABA Therapy/Behavioral Health (BCBS ONLY)
- Bariatric/Gastric Surgeries
- Breast Reductions (BCBS & MM)
- Gender Reassignment Surgery
- Transplants (Not Including Corneal Transplants)
We recommend a predetermination into TeamCare for the following procedures:
|Augmentative Speech Device (Durable Medical Equipment – DME)||Intacs||Proton Beam Therapy|
|Blepharoplasty (color photos required)||Implantable Miniature Telescope (IMT)||Provenge/Sipuleucel-T|
|Bone Growth Stimulator (DME)||JAS Splints/Mechanical Stretching Devices||Rhinoplasty|
|Breast Augmentation||Laminotomy/Laminectomy/Spine & Back Surgery||Scooter/Wheelchair (Durable Medical Equipment – DME)|
|Buy & Bill Specialty Drugs-High-Cost Drugs (Includes IV Therapy)||Laser Treatment of Congenital Port Wine Stain/Hemangiomas||Spinal Cord Stimulator|
|Capsule Endoscopy/Pill Cam||Lung Cancer Screening||Stereotactic Radiosurgery|
|Durable Medical Equipment (DME) – purchase/rental, repair or replacement||Manual Manipulation Anesthesia (MUA)||TENS Unit/Muscle Stimulator|
|Dynasplint/Dynamic Splint (DME)||Obstructive Sleep Apnea (Surgical Treatment)||Total Parenteral Nutrition – TPN|
|Enteral feeding and related supplies||Panniculectomy||Vagus Nerve Stimulator Implant|
|Gastrointestinal (GI) Motility Measurement (CPT Codes: 91112, 91132, 91133, and 91299)||Pectus Excavatum||Varicose Veins/Sclerotherapy|
|Genetic/DNA Testing/Genomic Assays||Penile Prosthesis||Video Monitored Electroencephalogram – V-EEG|
|Glucometer/Continuous Monitor/Glucose Monitor (Buy & Bill)||Photodynamic Therapy/Dermatologic Applications||Ventilator (Durable Medical Equipment — DME)|
|Hormone Replacement Therapy||Power Operated Cart/Wheelchair (Durable Medical Equipment – DME)||Wound Vac – (NPWT)(Durable Medical Equipment – DME)|
|Hyperbaric Oxygen Chamber||Prophylactic Mastectomy|
*A Pre-Determination of Benefits is not a guarantee of payment, and is contingent upon compliance with all Plan requirements.
Important medical predetermination reminders
Always verify eligibility and benefits first.
It is highly recommended that you submit the form 30 days prior to the scheduled procedure date.
Do not send in duplicate requests, as this may delay the process.
You must also complete any other pre‐service requirements, such as preauthorization, if applicable and required.
Fax information for each patient separately and always place the form on top of other supporting documentation; please include any additional comments if needed.
Per medical policy, if photos are required for review, the photos should be clear, in color, and faxed along with the form.
Fax each completed form to 877-PDB-6173 (877-732-6173). You can also submit the form and documentation online through the Message Center, or mail your request to TeamCare – A Central States Health Plan ATTN: Research & Correspondence, PO Box 5126, Des Plaines IL 60017-5126.