Get the free Pre-Determination Request Form - MedPartners

Three Rivers Medical Management Predetermination Request FAX to 2604793568 PHONE 8887730038 (toll-free) 2604793560 (local) ***Please attach pertinent clinical information on all Predetermination RequestsUPON

How to fill out pre-determination request form

How to fill out a pre-determination request form:

Obtain the pre-determination request form:

1. Contact your insurance company or visit their website to download the form.
2. Ask your healthcare provider for a copy if they have one specific to their practice.

Fill in the personal information:

1. Provide your full name, address, and contact details.
2. Include your insurance policy number, group number, and any other relevant insurance information.

Specify the procedure or treatment:

1. Clearly state the procedure or treatment for which you are seeking pre-determination.
2. Include the diagnosis, if known, or the reasons why you believe this procedure is necessary.

Attach supporting documentation:

1. Gather any medical records, test results, or other relevant documents that support the need for the procedure.
2. Make copies of these documents and attach them to the pre-determination request form.

Fill in the provider information:

1. Include the name, address, and contact details of the healthcare provider who will perform the procedure.
2. If applicable, provide the provider's National Provider Identifier (NPI) number.

Review and sign the form:

1. Read through the entire form to ensure all sections are completed accurately.
2. Sign and date the form, acknowledging that the information provided is true and accurate to the best of your knowledge.

Who needs a pre-determination request form:

Individuals planning to undergo a costly or complex medical procedure:

1. People who require surgeries, specialized treatments, or major dental work often use pre-determination request forms.
2. This helps to determine if their insurance will cover the procedure and if any out-of-pocket expenses will be incurred.

Patients who want confirmation of coverage before proceeding:

1. Some individuals prefer to have confirmation from their insurance company about the coverage and cost-sharing responsibilities for a particular procedure.
2. This allows for better financial planning and decision-making.

Healthcare providers looking for prior approval:

1. Many healthcare providers require pre-determination approval to carry out certain treatments or procedures.
2. It ensures they will be reimbursed for the services they provide.

Please note that specific requirements for the pre-determination request form may vary depending on the insurance company and the type of procedure involved. Always consult with your insurance provider or healthcare provider for any additional guidance or specific instructions.

For pdfFiller’s FAQs

What is pre-determination request form?

Pre-determination request form is a form used to request a determination from an insurance company about coverage and benefits for a specific medical treatment or service before it is provided.

Who is required to file pre-determination request form?

Anyone seeking medical treatment or services that may be covered by insurance is required to file a pre-determination request form.

How to fill out pre-determination request form?

The form typically requires information about the patient, the proposed treatment or service, and the healthcare provider. It is important to provide all requested information accurately.

What is the purpose of pre-determination request form?

The purpose of the form is to help individuals understand their insurance coverage, potential out-of-pocket costs, and any requirements for coverage before receiving treatment.

What information must be reported on pre-determination request form?

The form may require information such as the patient's name and insurance policy number, the healthcare provider's information, details about the proposed treatment or service, and any supporting documentation.

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