Before treatment: should I ask for a predetermination?

• The office's estimate is based on what the office knows about your plan. It's a helpful starting point, but the office may not know every limit or how much of your benefits other claims have used.
• A predetermination comes from the insurer itself, after it reviews your treatment plan and X-rays. It's the closest thing to a real answer you can get before treatment.

• A service your plan doesn't cover
• A frequency limit or waiting period
• Paying for a cheaper alternative instead of what was planned
• The missing tooth clause
• Whether your case meets the plan's criteria, which matters most for crowns, buildups, and deep cleanings. Most plans check this, but some predeterminations are only a cost estimate. If so, the response should say the claim is still subject to review.
• Records the insurer will want to see, so the claim isn't held up later

• Predetermination: a voluntary estimate. Most PPO and traditional plans offer it.
• Pre-authorization: required approval. Common in dental HMO plans, especially before seeing a specialist. If your plan requires it, skipping it can mean the plan won't pay.

A predetermination is the plan's estimate based on what it knows when it reviews your treatment plan. The final payment can still change if:

• You've hit a benefit limit by the day of treatment, such as your annual maximum or a frequency limit (for example, because other claims were paid first).
• Your coverage changed or ended, or your plan year reset.
• Your treatment, or the condition of your tooth, changed between the estimate and the visit.
• The records sent with the final claim don't support the treatment as it was approved.
• Another plan should pay first.
• Information sent with the request was wrong.
• Your predetermination was a cost estimate only, and the plan checks its criteria when the final claim comes in.

Some responses also say how long the estimate stays good, often about a year, though it varies. If yours doesn't say, ask the plan.

• Ask your dentist's office to submit it. They send the treatment plan and any X-rays.
• Allow time. Responses often come back within a week or two, but some can take a few weeks.
• Ask for a copy of the response, and schedule treatment soon after you get it, in the same plan year if possible.

• Pain, swelling, or infection. Don't put off urgent care to wait for a response. Ask your dentist which parts are urgent and which can safely wait for the answer.
• Routine care. Cleanings, checkups, and X-rays within your plan's limits usually don't need one.

If you don't have insurance, or you choose not to use it, there's no predetermination. Instead, ask for a written good faith estimate. Under federal rules, offices generally must give you one if you ask, or when you schedule care at least three business days ahead. If your final bill is at least $400 more than the estimate, you may be able to dispute it.