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The form instructs providers to avoid using it for utilization management requests and notes that predetermination is a courtesy review that does not replace precertification or prior approval requirements. It includes member demographics, provider information, applicable diagnosis and procedure codes (ICD-10, CPT/HCPCS), and panel test references, and provides submission and fax contacts for determinations.",{"@graph":63,"@context":110},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/federal-employee-program-postal-predetermination-prior-approval-request-form/288220/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/federal-employee-program-postal-predetermination-prior-approval-request-form/288220.png","ImageObject",442,249,{"name":88,"@type":89},"Skyler","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-24","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104],{"name":105,"@type":106,"acceptedAnswer":107},"How long should providers allow for a determination when a medical review is requested?","Question",{"text":108,"@type":109},"Providers should allow up to 15 days for a determination to be made when a medical review is being requested.","Answer","https://schema.org",{"og:url":78,"og:type":112,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":114,"canonical":78},"index,follow",{"doc_id":116,"site_id":56},288220,1790130668,{"code":4,"msg":5,"data":119},{"doc_id":116,"user_id":120,"nickname":88,"user_avatar":121,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":122,"file_id":123,"file_url":124,"file_type":125,"file_size":126,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":127,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":128,"faqs":129,"seo_title":130,"seo_description":61,"update_tm":131,"read_time":9},2336464648746,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Federal Employee Program® and Postal  \nPredetermination / Prior Approval Request Form  \nDate Submitted:  Pages attached (include cover and/or form):  Contact Name:  Contact Phone \\# :  Contact Fax \\# :   \n** Please be sure contact fax number is clear due to HIPAA, since decision letters maybe faxed to the provider.  \nThis form should not be used for Utilization Management requests such as Inpatient stays, Hospice care, Skilled Nursing stays, Residential Treatment stays, or Applied Behavior Analysis (ABA) therapy. Those requests should be sent to Utilization Management for review.  \nPlease complete this form when requesting predetermination or prior approval for a specifc procedure or service. Predetermination requests are never required and are offered as a courtesy review to check for benefts/coverage, and to ensure services meet medical criteria/guidelines. They do not take the place of any precertifcation/prior approval requirements. Failure to obtain any necessary authorizations may result in a denial or reduction in benefts. If the determination of this review will infuence the decision to proceed with treatment, Federal Employee Program® (FEP)/Postal (PSHB) recommends that nothing be scheduled until the fnal determination has been issued. A request for predetermination is not necessary for urgent or emergency medical treatment. (If a medical review is being requested, please allow up to 15 days for a determination to be made.)  \n\n| Member Name: | Member ID Number: |\n| --- | --- |\n| Date of Birth (mm/dd/yy): | Male Female |\n| Diagnosis (including ICD-10 Code): |  |\n| Procedure: Offce Outpatient |  |\n| Other |  |\n| Regarding lab panel tests/or genetic panels: |  |\n| Are these codes part of a panel(s)? Yes No |  |\n| If part of a panel or panels – what is the name of the panel(s)? |  |\n\nRequesting provider information below:  \n\n| Requesting Provider: | Provider No.: | NPI No: |\n| --- | --- | --- |\n| Telephone No.: | Fax No.: |  |\n| Address: | City: | State/Zip: |\n\nCodes on next page  \nRequested Procedure(s) or Equipment: CPT® or HCPCS Codes (required):  \n\n|  |  |\n| --- | --- |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n\nMember Name:  Date of Birth:  Subscriber ID:   \nFEP/PSHB Medical Policies can be accessed online: [https://www.fepblue.org/legal/policies-guidelines](https://www.fepblue.org/legal/policies-guidelines).  \nPlease return this completed form to: BlueCross BlueShield of Tennessee  \nPredetermination/ODM  \n1 Cameron Hill Circle, STE 0014  \nChattanooga, TN 37402-0014  \nYou may also fax this completed form to (423) 591-9091. If you have any questions, please contact BlueCross  \nBlueShield of Tennessee FEP Customer Service at 1-800-572-1003 or Postal Customer Service at 1-866-780-7742,  \nMonday through Friday, [8 a.m. to 6 p.m](8 a.m. to 6 p.m). (ET) .  \nIf provider/facility or supplier is out-of-network and requesting in-network benefts, please note that and attach the rationale for utilizing out-of-network sources.  \nPlease note: Final reimbursement determinations are based on member eligibility at the time of service, Medical Necessity criteria, applicable member copayments, coinsurance, deductibles, beneft plan exclusions/limitations, authorization/referral requirements and FEP/PSHB Medical Policy.  \nCPT® is a Registered Trademark of the American Medical Association. BlueCross BlueShield  \nof Tennessee, Inc. , an Independent Licensee of the BlueCross BlueShield Association 25FEP2996233 (1/25)","cbCaih0OkLnKJWtf","https://ap.wps.com/l/cbCaih0OkLnKJWtf","pdf",341872,"English","# Member Information\n# Requesting Provider Information\n# Requested Procedure(s) or Equipment\n# Submission Information","[{\"question\":\"How long should providers allow for a determination when a medical review is requested?\",\"answer\":\"Providers should allow up to 15 days for a determination to be made when a medical review is being requested.\"}]","Federal Employee Program - Postal Predetermination / Prior Approval Request Form | PDF",1789633250]