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.

Medical Predetermination of Benefits for Providers Request Form »


Important medical predetermination reminders

checkmark box Always verify eligibility and benefits first.

checkmark box It is highly recommended that you submit the form 30 days prior to the scheduled procedure date.

checkmark box Do not send in duplicate requests, as this may delay the process.

checkmark box You must also complete any other preservice requirements, such as preauthorization, if applicable and required.

checkmark box  Fax information for each patient separately and always place the form on top of other supporting documentation; please include any additional comments if needed.

checkmark box Per medical policy, if photos are required for review, the photos should be clear, in color, and faxed along with the form.

checkmark box 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.