Health Insurance Terms: What is a predetermination?

Have you ever been to the doctor and heard words that didn’t make sense? It’s common to be told you need a … (fill in the blank) before you can have a service or medicine. It can be very confusing, but your doctors and nurses can help. They should be able to explain how things work, especially when it comes to helping you feel your best and using your health insurance.

 For example, you may have been told you need a predetermination. You might be thinking, “A pre-what?” A predetermination of benefits is a review by your insurer’s medical staff to decide if they agree that the treatment is right for your health needs. Predeterminations are done before you get care, so that you will know early if it is covered by your health insurance plan. The predetermination of benefits depends on information your doctor sends to Blue Cross and Blue Shield of Oklahoma’s (BCBSOK) medical staff.

Here’s how predetermination works:

  • The doctor’s office will call BCBSOK to verify your benefits.
  • BCBSOK will decide if predetermination is needed, and let the doctor know.
  • If the doctor’s office learns you need a predetermination, the doctor will send the required details telling BCBSOK’s medical staff telling why you must have the treatment. If you feel like you want to do more, you can also submit a predetermination form for yourself.
  • The BCBSOK medical staff will consider the request, make a decision, and tell your doctor.

Now, you may be thinking, “If my doctor tells me I need something, why does it need a second approval? Shouldn’t the doctor’s instruction be enough?” Often, it’s important to have a medical person who knows more about your coverage to review the request. There may be another option that is just as successful for you and covered under your insurance. Many times, this will save you money – the treatment your doctor requests may not be covered under your plan. Other times, your plan may require that the doctor show you have tried other treatments first. For example, if you struggle with your weight, your doctor may tell you that you should have gastric bypass surgery. Your doctor may need to show that you have been on a medical weight loss plan first.

How Will I Know What Kinds of Services Might Need a Predetermination?
Here are some services that may require a predetermination. But remember, the details can be different for every plan.

  • Growth Hormone
  • Botox
  • Dental Implants
  • Breast MRI
  • Nasal Surgery
  • Breast Reduction

If your predetermination is approved, you can continue with the service or buy the medicine under the benefits covered by your health insurance plan. If your predetermination is denied, you can still have the service or buy the medicine if you want to, but you’d have to pay for all of it by yourself. You can also appeal the decision, which gives you the chance to provide more details to medical review that you think will change the decision.

If you ever have questions about a predetermination or anything else about your coverage, always feel free to look on our website, call us at the number on the back of your ID card, or drop your question in the comment area below! Always remember to keep your personal information private—we have a private message section available if you need to provide specific information about your question.

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