What Is a Predetermination of Benefits? (Dental & Medical)
A predetermination of benefits is a written estimate from your insurance showing exactly what they will pay before treatment. Learn how to request one for dental and medical procedures.
What Is a Predetermination of Benefits?
A predetermination of benefits (also called a pre-treatment estimate or pre-authorization) is a written statement from your insurance company that tells you exactly how much they will pay for a proposed treatment before you receive it. Unlike a regular estimate from your provider, a predetermination comes directly from your insurer and is based on your specific plan benefits, deductibles, and coverage limits.
How Predeterminations Differ from Pre-Authorization
While often confused, predeterminations and pre-authorizations serve different purposes. A predetermination estimates payment amounts but does not guarantee coverage. A pre-authorization (or prior authorization) is required approval before certain procedures and confirms the service is medically necessary. Some procedures require both: pre-authorization for approval and a predetermination to understand costs.
Dental Insurance Predeterminations
Dental predeterminations are especially valuable for expensive procedures like implants, crowns, bridges, and orthodontics. Your dentist submits the ADA claim form with procedure codes (CDT codes), X-rays, and clinical notes to your insurer. The insurance company reviews this information and returns a detailed breakdown of allowed amounts, coverage percentages, and your estimated out-of-pocket costs.
- Implants and implant-supported restorations
- Crowns, bridges, and dentures
- Root canals and oral surgery
- Orthodontic treatment (braces, clear aligners)
- Periodontal procedures (deep cleanings, grafts)
Medical Insurance Predeterminations
Medical predeterminations help you understand costs for planned surgeries, imaging studies, and other non-emergency procedures. They are particularly important for elective procedures where you have time to compare costs across providers and negotiate before treatment.
- Elective surgeries (joint replacement, hernia repair)
- MRI, CT scans, and advanced imaging
- Physical therapy and rehabilitation
- Specialty consultations and second opinions
- Durable medical equipment
Why Request a Predetermination?
Predeterminations protect you from surprise bills by revealing the actual allowed amounts your insurer has negotiated with providers. They expose alternate benefit clauses (where insurers pay for a cheaper alternative), annual maximum limits, and waiting periods that affect your coverage. Armed with this information, you can negotiate with providers, schedule strategically around benefit periods, or seek care elsewhere.
Limitations and What Predeterminations Do Not Guarantee
Predeterminations are estimates based on information available at the time. They do not guarantee payment if your coverage changes, if the actual procedure differs from what was submitted, or if you exceed annual maximums. Always verify your current coverage before treatment and keep the predetermination document for reference.
How to Request a Predetermination of Benefits
Gather procedure codes and fees
Ask your provider for a detailed treatment plan including all procedure codes (CDT for dental, CPT for medical) and their fees. For dental work, request the ADA claim form.
Submit the predetermination request
Have your provider submit the request to your insurance company with supporting documentation like X-rays, clinical notes, and medical necessity letters. Some insurers allow patients to submit directly.
Wait for the response
Dental predeterminations typically take 2-4 weeks. Medical predeterminations may take 1-2 weeks for standard requests or 72 hours for urgent cases.
Review the predetermination carefully
Check allowed amounts, coverage percentages, deductible status, annual maximum remaining, and any alternate benefit downgrades. Compare to your provider's quoted fees.
Use the information to negotiate
If your provider's fees exceed allowed amounts, negotiate a fee reduction. Consider timing treatment around benefit periods or annual maximum resets.
Frequently Asked Questions
What is a predetermination of benefits?
A predetermination of benefits is a written estimate from your insurance company showing how much they will pay for a proposed treatment before you receive it. It includes allowed amounts, coverage percentages, and your estimated out-of-pocket costs based on your current plan benefits.
How long does a predetermination take?
Dental predeterminations typically take 2-4 weeks. Medical predeterminations usually take 1-2 weeks for standard requests, though urgent requests may be processed within 72 hours.
Is a predetermination the same as pre-authorization?
No. A predetermination estimates payment amounts but does not guarantee coverage. A pre-authorization is required approval confirming a procedure is medically necessary. Some procedures require both.
Does a predetermination guarantee payment?
No. A predetermination is an estimate based on your current benefits and the information submitted. Actual payment may differ if your coverage changes, the procedure differs from what was submitted, or you exceed annual maximums.
Can I request a predetermination myself?
Some insurance companies allow patients to submit predetermination requests directly, but most require submission by the treating provider who can include necessary clinical documentation like X-rays and medical records.
What is an alternate benefit clause?
An alternate benefit clause allows insurers to pay only for a less expensive alternative treatment. For example, if you need a crown, they may pay only the amount they would cover for a filling. Predeterminations reveal these downgrades before treatment.
Get Help Understanding Your Predetermination
Upload your predetermination or treatment plan and our AI will analyze it, explain what your insurance will cover, and help you negotiate the best price.