Insurance and benefits
Dental Predetermination vs Preauthorization: What Your Team Needs to Know
Dental predetermination vs preauthorization is one of the most confusing pairs of terms at the front desk, partly because payers, plans and even the ADA's own glossary use them in overlapping ways. Both happen before treatment. Both involve sending the treatment plan to the payer. The difference is in what the payer's answer means: a predetermination tells you what the plan expects to pay, while a preauthorization tells you the plan agrees the treatment is covered. This guide explains each term, when you need one, what to send and how to keep the requests moving.
In short
- A predetermination is an estimate of benefits for a proposed treatment plan.
- A preauthorization is the payer's statement that the proposed treatment will be covered under the contract.
- Neither one replaces checking eligibility and the remaining maximum again on the day of treatment.
What is a dental predetermination?
The ADA Glossary of Dental Administrative Terms defines predetermination as "a process where a dentist submits a treatment plan to the payer before treatment begins." The payer reviews the plan and responds with what it would cover and pay. The same glossary points both "pretreatment estimate" and "prior authorization" to this entry, which is why you will hear all three used for the same request.
Offices usually send a predetermination for larger treatment so the patient can see a realistic portion before agreeing: crowns, bridges, implants, scaling and root planing, dentures and some oral surgery. Some plans also ask for one above a set dollar amount.
What a predetermination is not
A predetermination is an estimate based on the information the payer had when it reviewed the plan. The final payment still depends on the patient's eligibility on the date of service, the deductible and maximum left at that time, and any other claims paid in between. Most responses say so in their own fine print. That is why the estimate should be dated in the chart and benefits checked again before the appointment.
What is a dental preauthorization?
The ADA glossary defines preauthorization as a statement by the payer that the proposed treatment will be covered under the terms of the benefit contract. In practice, a preauthorization is a requirement rather than a courtesy: some plans will not pay for certain services unless they approved them first.
Preauthorization requirements are most common in state Medicaid and CHIP dental programs, some managed care plans and for certain services such as orthodontics, general anesthesia and some periodontal and surgical procedures. The rules vary by state and by plan, so check each payer's provider manual rather than assuming.
Predetermination vs preauthorization side by side
| Predetermination | Preauthorization | |
|---|---|---|
| What it answers | What the plan expects to pay | Whether the plan agrees to cover it |
| Required? | Usually optional, sometimes required above a dollar amount | Required by the plan for listed services |
| Skipping it | The patient may face a surprise balance | The claim may be denied |
| Common payers | Commercial PPO and indemnity plans | Medicaid, CHIP and some managed care plans |
| Is payment promised? | No, it is an estimate | Coverage, subject to eligibility and plan terms |
When should you send a predetermination?
Set a written policy so the decision does not depend on who is at the desk. A simple version:
- When the plan requires it, by procedure or dollar amount
- When the patient's portion depends on a plan rule you cannot confirm on the phone, such as an alternate benefit or a missing tooth clause
- When the treatment is large enough that a surprise balance would hurt trust
- When the patient asks for one before deciding
Our guide to frequency limits, waiting periods and the missing tooth clause explains the plan rules that most often change an estimate.
What to send with the request
A request that is missing documentation comes back asking for it, and the clock starts again. Send everything the first time:
- The treatment plan on the current ADA Dental Claim Form or electronically, with the CDT codes, tooth numbers, surfaces and fees
- Radiographs that show the teeth involved, current and clearly dated
- Periodontal charting for scaling and root planing and other periodontal procedures
- Intraoral photos where they show what an X-ray cannot, such as a fracture
- A short narrative explaining why the treatment is needed
Our guide to writing dental claim narratives covers what reviewers look for.
How to track predeterminations and preauthorizations
Requests stall when nobody owns them. Keep one list, either a report in your practice management software or a shared tracker, with:
- Patient, payer, procedures and date sent
- How it was sent and any reference number
- The date to follow up if there is no response
- The response, the approved or estimated amounts and the expiration date, if the payer gives one
- Whether the patient has been told and the appointment booked
Work the list on a fixed day each week. When a response arrives, update the treatment plan estimate, tell the patient and book the appointment while the approval is still valid.
How to explain a predetermination to a patient
Patients hear "we sent it to your insurance" and assume the answer is final. A short, consistent explanation prevents that misunderstanding and the difficult call that follows it. Tell the patient three things when you send the request:
- What it is: the plan is reviewing the treatment plan and will tell us what it expects to pay.
- What it is not: the estimate is not final, because the plan pays based on coverage and benefits left on the day of treatment.
- What happens next: we will call you when the response arrives, go over your portion and book the appointment.
When the response comes back, show the patient the numbers in writing: the fee, the estimated plan payment and the estimated patient portion, with the date of the estimate. If the plan applied an alternate benefit or a frequency limit, point to it on the estimate so the patient understands why their portion is higher than the coverage percentage suggests. Offer financing options your practice accepts if the portion is large, and note in the chart that the conversation happened.
If the patient waits months before scheduling, check eligibility and the remaining maximum again before the visit, and send a new request if the payer's response has expired.
Who should handle these requests?
Predeterminations and preauthorizations take focused time: assembling attachments, checking each payer's rules and following up. A dental billing virtual assistant can own the list from request to response, while an insurance verification assistant confirms eligibility again before the visit.
Questions about predeterminations and preauthorizations
Does a predetermination promise payment?
No. It is an estimate based on the information the payer had at the time. Payment still depends on eligibility, deductibles and the maximum left on the date of service.
Are prior authorization and predetermination the same thing?
The ADA glossary treats prior authorization as another name for predetermination, while it defines preauthorization as the payer's statement that treatment will be covered. Payers use the words differently, so read each plan's own definition.
How long does a predetermination take?
It varies by payer and by how the request was sent. Electronic requests with complete attachments are usually answered faster than paper. Track every request and follow up on a set day.
Should we check benefits again after a predetermination comes back?
Yes. Check eligibility and the remaining maximum before the appointment, since other claims may have been paid in between.
Sources
- ADA Glossary of Dental Administrative Terms: predetermination, preauthorization, prior authorization and pretreatment estimate.
- ADA Dental Claim Form: the current claim form.