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Dental Predetermination Explained

Dealing with insurance can be complicated, confusing and at times frustrating. Here is everything you need to know about processing dental predeterminations and how it can benefit your dental practice.

Dental Intelligence


June 1, 2023

Navigating the world of dental predeterminations can be complex and confusing, particularly for patients. Of course, insurance companies are going to make it as difficult as possible for patients to receive coverage for their benefits. How can you deal with these predeterminations?

Insurance companies aren’t in the business of losing money. However, the right practices can help you and your patients by increasing the chance of treatment plan acceptance and preventing denials. Here is everything you need to know about processing dental predeterminations and how it can benefit your dental practice.

What Are Dental Predeterminations?

With a dental predetermination, an insurance company makes an educated guess as to how much the out-of-pocket portion will be for a proposed treatment plan. Compared to a confirmation of coverage, which is an estimated percentage, a predetermination refers to a specific dollar amount for the planned services.

While it varies depending on specific payers and their dental plans, a predetermination is usually necessary for treatment plans over $300. For patients, this allows them to get an idea of how much they’ll have to pay for their covered services and their financial obligation for their procedure.

While they’re not actually a guarantee that the insurance company will pay that amount, predeterminations are still a valuable form of assistance for both you and your patients to help them with financing and paying for their proposed services.

The Difference Between Predeterminations and Preauthorizations

A dental preauthorization1 may seem similar to a predetermination, but it’s slightly different. Essentially, a preauthorization is when the insurance company (or another third-party payer) indicates that the treatment plan you propose for your patient will qualify as covered services under the patient’s dental benefits. The predetermination occurs after the preauthorization and usually includes information that includes:

Tips for Processing Patient Predeterminations

How can your dental practice make it as easy as possible to process predeterminations for your patients? Here are a few tips.

1. Streamline Your Claims Processing and Payment Systems

Dealing with insurance companies, benefits plans, and financial coverage can be challenging, to say the least. That’s why you should consider investing in a more efficient and organized claims processing system like Dental Intelligence Insurance.

With a user-friendly and comprehensive practice performance solution, you can make your daily dental insurance and financial workload much lighter. With Dental Intelligence Payments you can send individual or bulk text messages, accept different types of payment options, and keep all your statements safe and secure. A streamlined system also improves the patient's experience by removing a lot of the hassle associated with paying for covered dental services and treatment plans.

2. Define Your Problem Areas

In every dental office, there are certain companies and dental plans that simply cause a headache for you and your staff. For example, maybe one specific insurance company frequently denies coverage for services or sends predeterminations or benefits estimates that are far different than what you or the patient expected. Sometimes, it takes a lot of trial and error to discover what works with certain payers — and what doesn’t.

You may want to consider developing a template that includes a list of the required documentation and paperwork necessary to process determinations for that particular company. Be sure to include any possible piece of paperwork that could assist the payer in their decision, as many times it can be a long wait to hear back, during which time you aren’t making any money.

3. Keep General Template Drafts on Hand

As we just said, making a template for documentation and X-rays makes it far simpler to process predeterminations, regardless of the specific insurance company. While it may take some extra time in the beginning to develop these, the benefits far outweigh the initial hassle.

Once you create the template, it only takes a little editing, though it depends on the specific patient. Plus, it sets a precedent with the insurance company ,so they know what to expect from your office when you send in predeterminations.

Trust the Professionals at Dental Intelligence

Learning how to process dental predeterminations isn’t the easiest task for many dental professionals. Actually, the entire scenario of billing medical insurance for dental procedures often involves a lot of documentation, administrative work, time-consuming communication, and, well, red tape. However, with help from Dental Intelligence and our practice performance solution, you can cut through that red tape with a sharp pair of scissors.

Interested in learning more about how we can help you intelligently shape the future of your practice? Schedule a demo of our product today.



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