A trip to the doctor’s office can sometimes require a dictionary. “Ah, yes, you need a (insert words that may as well be Latin) before you can have this procedure or be prescribed this medicine.”
If you’ve ever had this conversation with your doctor, then you know how confusing it can be. Luckily, using your health insurance doesn’t have to be confusing. For example, at some point you may be told you need a predetermination. You might think, “A pre-what?”
A predetermination of benefits is a review by your insurer’s medical staff. They decide if they agree that the treatment is right for your health needs. Predeterminations are done before you get care, so 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 Texas (BCBSTX) medical staff.
You may think, “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 review the request. Maybe there will be another option that’s just as effective and covered under your plan. Making sure your treatment is covered will ultimately save you money. Sometimes, your plan may require that your doctor show you have tried other treatments first. For example, if you struggle with your weight, your doctor may recommend gastric bypass surgery. Your doctor may need to show that you have tried a medical weight loss plan first.
Here’s a breakdown of the way predetermination works:
- The doctor’s office will call BCBSTX to verify your benefits.
- BCBSTX will decide if predetermination is needed and let the doctor know.
- If predetermination is needed, your doctor will send the required details telling BCBSTX’s medical staff why you must have the treatment.
- The BCBSTX medical staff will consider the request, make a decision, and tell your doctor.
Here are some services that may require a predetermination. Remember, the details can be different for every plan.
- Botox
- Breast MRI
- Breast Reduction
- Dental Implants
- Growth Hormone
- Nasal Surgery
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 choose to have the service or buy the medicine, but you will have to pay all the costs yourself. You can also appeal the decision. An appeal gives you the chance to provide the medical review team with details you think will change their decision.
If you ever have questions about a predetermination or anything else about your coverage, 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 offer a private message section if you need to provide specific information about your question.
Originally published 3/172015; Revised 2021
Health insurance is complex even for the savviest of professionals. That’s why Healthcare Consultants are so important for both companies and individuals. As healthcare consultants, one of the most frequently asked questions we receive is what is predetermination?
For many, the first time they hear it is when a doctor recommends a surgical procedure. That procedure must first be approved by the health insurance provider before the physician can set any dates to proceed. But what if you have the choice to move forward with predetermination? Is it really the best option for you? Further still, what is predetermination and why should you care?
The answer might surprise you.
What is Predetermination?
Predetermination for benefits of your health insurance plan is a process through which your insurer’s medical staff reviews the recommended treatment. If they agree with your doctors and specialists that you need the health treatment and that it is right for you, your predetermination is approved. They are typically done before you receive care, which gives you enough time to see if the procedure is covered by your health plan. Ultimately, the decision is made based on the information your doctor provides to your health insurance provider’s medical staff.
For this reason, it is critical that you and your doctor thoroughly explain the procedure in your predetermination letter. Insurance companies tell providers what medical procedures require a predetermination letter before they can be approved. Most of these services include experimental, investigational, or cosmetic services. A few examples of these services might be:
- Breast Reduction
- Botox
- Nasal Surgeries
Anything not deemed life threatening typically falls under the predetermination requirement. Providers must submit the predetermination letter using their letterhead. If they fail to send a letter in with the request for coverage, the claim is likely to be denied.
Your doctor is also required to submit supporting documents. These will include information about previous treatments that were tried and the results of those treatments. A list of all medications administered is another required bit of information from your doctor. Symptoms and your history will need to be included in that letter. Test results, such as MRIs, X-Rays, and diagnostic procedures must be reported to your insurer to guarantee that every alternative option has been pursued.
To see a sample of the predetermination form, please visit this link.
According to the American Medical Association, physicians should submit these letters for any procedure that is frequently denied by the insurer as being deemed “unnecessary.” Depending on the care you require, this process should begin as quickly as possible. To avoid waiting months to have your service covered start this process as soon as your doctor recommends the procedure.
But you might still be wondering why predetermination is good for you. After all, it generally seems like more of a hassle than it is worth. However, as healthcare consultants, we know there are multiple benefits of predetermination for both you and for your insurer.
Benefits of Predetermination
The way that insurers are set up is a third party system. You need the care, your physician recommends treatments and medications, but it is your insurance provider who steps in and determines whether or not those treatments and medications are necessary.
Originally, this system was set up to help you save the greatest amount of money possible. Unnecessary medical procedures and treatments can cost tens of thousands of dollars if left unchecked. The good news is, they don’t have to. Your insurer will use their knowledge to compare recommended treatments with industry practices. If they see that your health requires the treatment, it will be approved. If they see another, more affordable, option for treatment, they will deny the claim.
However, it is not just affordability at stake. Your insurer’s other job is to look out for your health. To protect their policy holders, insurers will investigate health claims made by doctors to see if there is an alternative option that could provide the same or better results with a less invasive process. That also saves you from investing your time and energy on a medical procedure that does not get the results you need.
When your health is at stake, nothing is more important than getting the best care possible. That is what your insurer is trying to help you do, in most instances. Yet, the bottom line does play a role in approval rates.
Despite these benefits, some providers are turning to an alternative to traditional patient-physician relationships: Direct Primary Care. You can read more about that at The Heritage Foundation.
What Happens if a Predetermination is Denied?
If your insurer determines that the requested procedure is either not right for you based on the history of your health or they do not deem it a ‘necessary’ procedure, you have two options to proceed.
The first option is to proceed with the treatment but pay for it completely out of pocket with no assistance from your insurer.
The second option is to file an appeal for the claim. In some instances, an insurer will deny your claim because there was insufficient information submitted either by you or by your physician. You also may not have had enough tests done to determine that the treatment was necessary. There could also be errors in the diagnostic codes sent through. If you want to appeal, you must first identify why your claim was denied and then follow through by meeting the demands of the predetermination letter.
However, it is important to recognize there is a difference between predetermination and pre-authorization. Let’s briefly examine the difference.
How Predetermination is Different from Preauthorization
Because of the confusion over medical terminology, some patients get confused about the difference between predetermination and preauthorization.
Preauthorization is the process that allows providers to determine if coverage is secured and approved of by the payor for the treatment. In no way does it guarantee reimbursement of the services. Regardless, failing to get preauthorization could cause a non-reimbursement for your treatment. Keep in mind that this process can take up to thirty days to be approved. Pay special attention to your preauthorization number on the document to ensure that that your claim is accurately submitted and reported back to you. To send in an appeal letter you have to have that number, so make sure to keep up with any documentation provided.
Predetermination, on the other hand, gives you complete confidence that your benefits coverage will kick in. This predetermination gives you a peace of mind regardless of the treatment you’ve applied for. However, these requests can also take up to forty-five days for approval.
As a rule, we highly recommend predetermination for both patients and providers. Waiting to get that approval could cause serious coverage issues. Don’t wait!
For more information about predetermination, how it works, what to expect, and how to ensure your request is approved feel free to contact the Healthcare Consultants Inc. team right here in Houston, Texas.