Predetermination Request Form Instructions - BlueCrossMN: Fill out & sign online

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Click ‘Get Form’ to open the Predetermination Request Form in the editor.
Begin by entering the Today’s Date and Scheduled/Anticipated Service Date at the top of the form. This information is crucial for processing your request.
Fill out the Provider Data section, including details for the submitting provider and ordering physician. Ensure all fields are completed accurately to avoid delays.
In the Member Data section, input the member identification number, group number, and patient’s date of birth. Double-check these entries for accuracy.
Attach any necessary documentation that supports your request in the Documentation section. Select all applicable options to ensure a comprehensive review.
Once all fields are filled out, review your entries for completeness before submitting. Remember to fax or mail your request as indicated in the instructions.

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