How to Fill Out and Submit the TeamCare Prior Authorization Form

The TeamCare prior authorization form, officially called the Medical Predetermination of Benefits (PDB) request, is submitted by your healthcare provider to confirm whether a planned procedure, drug, or piece of equipment meets TeamCare’s coverage rules before you receive the service. Providers submit the completed form and supporting records online at MyTeamCare.org, by fax to 877-732-6173, or by mail to PO Box 5126, Des Plaines, IL 60017-5126, and TeamCare recommends submitting at least 15 business days before the scheduled service date.¹² A predetermination is not a guarantee of payment. Actual reimbursement still depends on your eligibility and compliance with plan rules on the date of service, but getting one before a costly procedure is the best way to avoid a surprise bill for a treatment the plan won’t cover.

When a Predetermination Is Needed

Before filling anything out, confirm which track your request belongs on. TeamCare splits predeterminations into two groups, and only one of them uses the TeamCare PDB form.¹

Four categories go through BlueCross BlueShield of Illinois at bcbsil.com instead:

ABA therapy and behavioral health
Bariatric and gastric surgeries
Gender reassignment surgery
Transplants, except corneal transplants

Everything else that TeamCare recommends predetermining uses the PDB form covered here. That list includes cosmetic-adjacent surgeries such as blepharoplasty (which requires color photos), breast augmentation or reduction, rhinoplasty, and panniculectomy; vein and vascular procedures including TAVR; durable medical equipment such as power wheelchairs, ventilators, wound vacs, and TENS units; high-cost buy-and-bill drugs; total parenteral nutrition and enteral feeding; genetic testing; proton beam, neutron beam, and stereotactic radiation; implantable devices including spinal cord and vagus nerve stimulators; and sleep apnea surgery, hyperbaric oxygen therapy, hormone replacement therapy, and photodynamic therapy.¹

Anything that could be considered cosmetic, and any procedure where medical necessity might be questioned, is worth running through a PDB even if it doesn’t appear on the list. Skipping the predetermination on a borderline procedure is a gamble. You may not learn the plan treats it as non-covered until after you’ve had it done.

Completing the Form

The form can be filled out through a registered provider account at MyTeamCare.org with no printing involved, or downloaded as a PDF, completed, and sent by fax or mail.² The information required is the same either way.

Member and Patient Information

Enter the member’s full name and TeamCare ID number from the benefits card, which starts with “TEA” followed by digits. The patient’s name and date of birth go in separate fields, since a dependent receiving care is not the same person as the member. Three yes-or-no questions follow about other insurance, work-related injury, and motor vehicle accidents or possible subrogation. Any “yes” needs a brief explanation.¹

Provider Sections

The form asks who is making the request and where the response should go, then splits provider details into two sections.¹ Section 1 covers the ordering physician, the doctor recommending the procedure, and uses that individual’s Type 1 National Provider Identifier along with specialty, name, phone, contact person, and address. Section 2 covers the rendering provider or facility, the surgeon, specialist, or hospital actually performing the service, and uses the organization’s Type 2 NPI. If the ordering and rendering providers are the same person, check “Yes” and skip Section 2.

Getting the NPI types right matters. A Type 1 identifies an individual practitioner; a Type 2 identifies an organization. Entering a facility’s NPI in the ordering-physician field, or the reverse, can cause the request to be routed incorrectly.

Service and Coding Details

Section 3 is where the clinical request takes shape. Check the place of service (provider office, outpatient facility, inpatient facility, home, or other) and the type of service (surgery, Rx drug, buy-and-bill drug, DME, genetic testing, radiology, therapy, enteral or parenteral nutrition, or other). Enteral or parenteral requests have additional fields for the time frame in weeks or months and the method of administration.¹

Then enter CPT or HCPCS codes for every planned service and ICD-10 diagnosis codes that explain the underlying condition. These codes are the primary language TeamCare uses to match the proposed treatment against its coverage policies, so make sure they line up with what the clinical records describe. A CPT code for a major surgery paired with chart notes describing only a minor office visit will trigger an immediate denial. A comments field at the bottom captures context that doesn’t fit the coded fields.

Documentation That Supports Medical Necessity

The form instructs providers to attach supporting information where applicable: lab and test results, X-rays, the patient’s current condition, medical history, evaluation and progress notes, records of conservative treatment already attempted, and color photos.¹ The goal is a file that tells a clear clinical story: this is the diagnosis, this is what was tried first, this is why this procedure is the appropriate next step.

Imaging and lab results should match the diagnosis codes on the form. For a blepharoplasty, photos need to show functional impairment, not just the appearance of the eyelids. For DME requests, the documentation should explain why off-the-shelf alternatives are inadequate. Surgical requests benefit from the surgeon’s notes detailing anatomical sites and expected functional improvement. Vague chart notes and missing measurements are the most common reason TeamCare sends the request back for more information, which drags out the timeline.

How to Submit

Three channels are available for the completed form and attachments:¹

Online, through a registered provider account at MyTeamCare.org. This is the fastest option and the one TeamCare encourages.²
Fax, to 877-732-6173.
Mail, to PO Box 5126, Des Plaines, IL 60017-5126.

If you fax or mail, keep a confirmation page or tracking number. Clinical packets are often substantial, and proof of delivery protects you if TeamCare says it never received the request. Online submissions generate confirmation automatically.

Timeline and What Comes Back

A predetermination is treated as a pre-service claim under ERISA. Federal rules require the plan to issue a decision within 15 days of receiving the request. TeamCare can extend that once by another 15 days for reasons beyond its control, but it has to notify you before the first 15-day window closes and tell you when to expect an answer.³

If something is missing, TeamCare will send a request for additional information that spells out exactly what it needs, and you get at least 45 days to respond. The decision clock pauses while the plan waits.³ This is where thin documentation hurts most. The request isn’t denied; it just drifts past the scheduled surgery date.

When review is complete, TeamCare sends an Estimate of Benefits notification to both the member and the provider. It states whether the services are approved, an itemized estimate of the plan’s payment, and the member’s expected remaining liability. That estimate is still contingent on eligibility and plan compliance on the actual date of service.¹

Urgent Requests

When a delay could seriously jeopardize your health, federal rules compress the schedule. If a physician familiar with your condition tells TeamCare the request is urgent, the plan must decide within 72 hours. If more information is needed, you’ll hear within 24 hours and have at least 48 hours to respond, and TeamCare then has another 48 hours to decide.⁴

The PDB form itself has no urgent checkbox. The urgency designation comes from the treating physician contacting TeamCare directly, typically by phone or a cover letter, explaining why the standard timeline would threaten the patient’s health. If a 15-day wait is medically untenable, that call needs to happen alongside the form submission.

If TeamCare Denies the Request

A denial notice will state the specific clinical reasons. You have two rounds of internal appeal available.⁵

The first appeal can be filed through the official appeals form in your MyTeamCare account, by written letter, or through the Message Center. A letter needs your name, address, TeamCare ID number, claim number, the patient’s name and relationship, the date of loss, and the specific reason you disagree. Include a copy of the denial or Explanation of Benefits and any additional medical records that respond to the clinical reason TeamCare cited. Appeals go to the Research & Correspondence Department, TeamCare, A Central States Health Plan, PO Box 5126, Des Plaines, IL 60017-5126, or by fax to 847-518-9794.⁵

A second and final internal appeal must be filed within 180 days of the first-appeal denial.⁵ ERISA guarantees at least 180 days from any adverse determination to file an appeal, and missing that deadline generally closes the door. Courts typically won’t hear a case if administrative appeals weren’t exhausted first.³

After both internal appeals, you may qualify for external review by an independent third party, which applies to denials involving medical judgment or a determination that a treatment is experimental. You have four months from the final internal denial to file. Standard external reviews are decided within 45 days, and expedited reviews within 72 hours. Your final denial letter will identify the organization that handles external review for your plan; if the HHS-administered federal process applies, filing is free at externalappeal.cms.gov.⁶

1
TeamCare. Medical Predetermination of Benefits Request Form
2
TeamCare. Do You Need a PDB
3
eCFR. 29 CFR 2560.503-1 – Claims Procedure
4
U.S. Department of Labor. Filing a Claim for Your Health Benefits
5
TeamCare. How to Appeal a Claim
6
HealthCare.gov. External Review