Pre determination of benefits for insert your name id. For example a diagnosis of fatigue bone pain or weakness is not specific a diagnosis.
If you are not sure if the predetermination of benefits process applies to a test or service your doctor asks.
Predetermination letter sample. Date your insurance company name pharmacy benefit manager name and address re. The first set is designed to be sent to third party payers and the second set is designed to be sent to employers. The list in the letter does not include a test my doctor asked me to have.
Patient s insurance identification number. These include dental implants breast reduction botox treatments nasal surgery. The processing time will usually be.
How do i know if the test is included in the predetermination of benefits process. The diagnosis must be specific. Certain services and procedures often require a pre determination letter although they can differ depending on your health insurance provider.
Predetermination of benefits for. Fax each completed predetermination request form to 800 852 1360. Sincerely your name and address letter requesting predetermination of benefits for medication.
Date your insurance company name re. Sample letter of medical necessity must be on the physician providers letterhead form 1132 07 2011 please use the following guidelines when submitting a letter of medical necessity. The blue cross and blue shield of illinois website lists services that generally require the pre determination letter.
Patient sample letters the council on dental benefit programs has developed two sets of sample letters to help address problematic language found in a patient s explanation of benefits eob statements. Us non 0314 0044 1 letter requesting predetermination of drug coverage. Submission of documents by provider as part of the predetermination process does not preclude the blue cross and blue shield plan from seeking additional information or documents from provider in relation to its review of other requests or matters.
Pre determination of medical benefits this form will assist you in obtaining a pre determination as to whether a particular service or supply will be eligible under the johnson johnson health care plan and if it meets the medical necessity and reasonable and customary guidelines. Name of group if applicable id number. Insert your group name or number.
Patient s name group group number. Insert your identification number group. Determination letter the insurance company s medical staff reviews the pre determination letter and attachments to decide whether the service is covered under the patient s health care insurance.