Health Insurance Terms: What is a predetermination?

Health Insurance Terms: What is a predetermination?

Health Insurance Terms: What is a predetermination?

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 New Mexico (BCBSNM) 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 BCBSNM to verify your benefits.
  • BCBSNM will decide if predetermination is needed and let the doctor know.
  • If predetermination is needed, your doctor will send the required details telling BCBSNM’s medical staff why you must have the treatment.
  • The BCBSNM 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 8/18/2015; Revised 2021

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