Blue Review
A Provider Publication

September 2021

Voluntary Predetermination Requests: Use the Availity® Attachments Tool and Other Helpful Resources

The Utilization Management section of our Provider website outlines three types of pre-service review: Prior Authorization, Pre-notification and Predetermination. There’s a page with more information to help you navigate when and how to submit a request for each type of review. For a quick summary, see our Utilization Management Process Overview (Commercial) – it offers a high-level decision tree specific to requests for commercial, non-HMO Blue Cross and Blue Shield of Illinois (BCBSIL) members.

Checking eligibility and benefits is an important first step before providing care and services to any BCBSIL members. This step helps you determine if prior authorization or pre-notification may be required for our non-HMO members. If prior authorization or pre-notification aren’t required, your next step for commercial, non-HMO members is to consider if you’d like to submit a voluntary predetermination request. 

Why submit a voluntary predetermination request?
Submitting a request for predetermination can help confirm coverage and medical necessity criteria. Is there a medical policy for the service/procedure? Check our Medical Policy Reference List – it shows procedure codes for services that are subject to medical necessity review, based on our medical policies. To help avoid post-service review for these codes/procedures, submit a voluntary predetermination request prior to rendering services.

How to Submit Online Predetermination Requests
 If you’ve decided to request a predetermination, remember you can submit it to us online by using the Attachments Tool on the Availity Provider Portal. Here’s how:

  1.  Log in to Availity
  2.  Select Claims & Payments from the navigation menu
  3.  Select Attachments – New
  4.  Select Send Attachment; then select Predetermination Attachment
  5.  Within the tool, download, complete and save the Predetermination Request Form 
  6.  Upload the completed form and attach supporting documentation
  7.  Select Send Attachment(s)
  8.  Use Availity’s Attachments Dashboard to confirm your online submission was received by BCBSIL

For more details, see our Electronic Predetermination of Benefits User Guide. If you need further help or customized training, email our Provider Education Consultants. Be sure to include your name, direct contact information, Tax ID and/or billing National Provider Identifier (NPI).

Reminders

  • You must be registered with Availity to use the Attachments tool. You can sign up today at Availity, at no charge. For registration help, call Availity Client Services at 800-282-4548. 
  • If you don’t have online access, you may continue to fax and/or mail predetermination of benefit requests along with a completed Predetermination Request Form (available in the Forms section of our Provider website) and pertinent medical documentation.
  • Per BCBSIL’s Medical Policies, if photos and/or X-rays are required for review, email this information to Photo Handling. The body of the email should include the patient’s first name and last name, group number, subscriber ID and date of birth.
  • Urgent care requests include any request for a predetermination with respect to which: The application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the member or the ability of the member to regain maximum function; or, in the opinion of a physician with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.

This information does not apply to requests for government programs (Medicare Advantage, Illinois Medicaid) or any of our HMO members.

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 BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity.

Checking eligibility and/or benefit information and/or obtaining prior authorization, pre-notification or predetermination 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, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, contact the number on the member’s ID card.

The Medical Policy Reference List is not an exhaustive list of all codes. Codes may change, and this list may be updated throughout the year. The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply.