Predetermination
A process by which a dentist submits a proposed treatment plan to an insurer before providing care, in order to receive an estimate of the carrier's benefit payment.
Full Definition
Predetermination (also called pre-treatment estimate or prior estimation) is a voluntary—and in some cases carrier-required—process in which the dental provider submits a proposed course of treatment and supporting documentation to the insurance company before treatment begins. The carrier responds with an estimate of what it will pay, but this is not a guarantee of payment; actual benefits are determined at the time of claim submission based on eligibility and plan provisions at that time. Editors must distinguish predetermination from pre-authorisation: the latter is a mandatory approval required before treatment can proceed, while predetermination is typically advisory. Predetermination responses are often used in patient financial planning communications and must be edited with appropriate disclaimers about their non-binding nature.
Usage
Usage note: Always include a disclaimer when editing patient-facing predetermination letters stating that the estimate is not a guarantee of payment. Distinguish clearly from pre-authorisation, which is a binding approval requirement.
In Context
- "After submitting a predetermination for the proposed crown on tooth #3, the office received an estimate showing 50% coverage under the patient's major restorative benefit." — Patient financial consultation letter
- "Editors should add a non-guarantee disclaimer to any predetermination response letter before it is sent to the patient." — Practice management communication template