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Web procedure (cpt)/hcpcs codes for requested services along with icd10 diagnosis codes must be listed on the form. We offer this service as a. Web select send attachment (s) fax or mail: Web how to submit a prior authorization. Prior authorization may be required via bcbstx's medical management, evicore ®. Complete the predetermination request form and fax to bcbstx using the appropriate. Web a predetermination of benefits is a voluntary request for written verification of benefits prior to rendering services. On july 30, 2020, blue cross and blue shield of texas (bcbstx) implemented an electronic. Upload the completed form and attach supporting. Web within the tool, select send attachment then predetermination attachment. Web electronic predetermination of benefits user guide.