A pre-determination of benefits, also called a pre-treatment estimate, is an inquiry of patient eligibility and service coverage, along with estimated associated costs. Pre-determinations are sometimes confused with prior authorizations, but they are not the same. A prior authorization is essentially a pre-submission of planned procedures to determine medical necessity and provides written approval to proceed with a planned service. Prior-authorizations are commonly associated with government programs such as Medicaid, though typically not a requirement with employer-sponsored commercial plans such as a PPO.
In contrast, pre-determinations are designed to inform the patient and, while not required, are often highly recommended. This is especially the case where procedure coverage or patient eligibility is uncertain and/or when the procedure may be costly. Examples might include crowns, prosthetics, oral surgery, surgical periodontal or endodontic procedures, and orthodontics. A pre-determination will make it easier to plan treatment and estimate expenses, though it is important to note that any pre-determination is only valid for ninety (90) days.
Specifically, a pre-determination will help to verify the following:
- The patient’s eligibility for the submitted service under their dental contract – this is not a guarantee, as eligibility may change between the time the pre-determination is completed and services are performed
- Whether that procedure is a covered benefit under the patient’s plan
- Delta Dental's estimated share of the costs
- Patient responsibility, including remaining deductible and any maximums
There is no fee for a pre-determination for either you or your patient. Additional information on pre-determinations is available in your Delta Dental of Virginia Participating Dentist’s Handbook.
Having a pre-determination will allow dentists to review proposed treatment with a patient and to make a decision on proceeding. Pre-determinations can help avoid patient confusion and can assist them in making financial arrangements in advance. Perhaps most importantly, there is less risk of a surprise when the procedure is completed and the claim submitted.
Michael D. Weitzner, DMD, MS
Dental Director, Delta Dental of Virginia
