Predetermination Request Reminders
A predetermination of benefits is a voluntary, written request for review of treatment or services, including those that may be considered experimental, investigational or cosmetic.* Prior to submitting a predetermination of benefits request, you should always check eligibility and benefits first to determine any pre-service requirements. A predetermination of benefits is not a substitute for the pre-certification process.
To submit a predetermination of benefits request, use the predetermination request form. Please note that predetermination requests must be sent to the Blue Cross and Blue Shield (BCBS) plan that holds the patient’s policy.
Faxing your information may help expedite the review process. For Blue Cross and Blue Shield of New Mexico (BCBSNM) members, fax your completed predetermination request form to BCBSNM at 505-816-3608, along with any supporting documentation. Approvals and denials are usually based on provisions in our medical policies. BCBSNM will notify you when the outcome has been reached.
For out-of-area BCBS members, an online "router" tool is available to help you locate plan-specific pre-certification/preauthorization and medical policy information. When you enter the alpha prefix from the member's ID card, you will be redirected to the appropriate BCBS plan's website for more information.
*For Federal Employee Program members, a predetermination of benefits review is required for the following services: outpatient/inpatient surgery for morbid obesity; outpatient/inpatient surgical correction of congenital anomalies; and outpatient/inpatient oral/maxillofacial surgical procedures needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth.
Please note that the fact that a guideline is available for any given treatment, or that a service or treatment has been pre-certified or pre-determined 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 services were rendered.