Requesting Predetermination of Benefits

As a reminder, predetermination of benefits requests may be submitted electronically to Blue Cross and Blue Shield of Texas (BCBSTX) through iExchange^®, our online benefit preauthorization and predetermination of benefits tool. Providers also may upload attachments, check status and obtain online approval information via iExchange. This online tool is available to physicians, professional providers and facilities contracted with BCBSTX. iExchange may be accessed directly or through the Availity^TM Web portal and is designed to help save you time by reducing the amount of calls and written inquiries submitted to BCBSTX.

If you need to submit a paper predetermination of benefits request to BCBSTX, it is important to send the pertinent medical documentation using our Predetermination Request Form. This form is available in the Education and Reference Center/Forms section of our website at bcbstx.com/provider. Beginning Dec. 1, 2017, written predetermination requests must be submitted using the Predetermination Request Form. Please note that, as of Jan. 1, 2018, paper requests that are received at BCBSTX without the Predetermination Request Form will be returned to the submitting provider, along with instructions to resend the request using the appropriate form.

Checking eligibility and benefits is always an important first step, prior to submitting predetermination of benefits and other pre-service requests. Eligibility and benefits requests may be submitted electronically through Availity, or your preferred Web vendor. Predetermination of benefits requests are not a substitute for the eligibility and benefits process.

To learn more about iExchange and other electronic options, visit the Provider Tools section in our online Education and Reference Center. For personalized online training regarding electronic tools, contact our Provider Education Consultants at PECS@bcbstx.com.

Note: This information does not apply to Blue Cross Medicare Advantage HMO^SM and Blue Cross Medicare Advantage PPO^SM members.

Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized 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. If you have any questions, please call the number on the back of the member’s ID card.

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 BCBSTX. iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by third party vendors such as Availity or Medecision. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.

Blue Cross^®, Blue Shield^® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.