Insurance term
Preauthorization (Predetermination)
Definition
A preauthorization, usually called a predetermination or pretreatment estimate in dentistry, is a request sent to the payer before treatment asking what it will cover.
Why it matters for the front desk
For crowns, bridges, implants and periodontal treatment, a predetermination gives the patient an estimate from the payer before they commit. Most dental predeterminations are not a guarantee of payment: the final amount depends on eligibility, remaining maximum and deductible on the date of service. Some plans, such as many Medicaid and HMO plans, require prior authorization before treatment. Responses can take weeks, so submit them early.
Related terms
- Claim Narrative A claim narrative is a short written explanation sent with a claim to show why a procedure was needed.
- Annual Maximum The annual maximum is the most a dental plan will pay toward a patient's care in one benefit year.
- Downgrade (Alternate Benefit) A downgrade, or alternate benefit, is a plan rule that pays for a less expensive treatment than the one performed.