Dental Predetermination vs Pre-Authorization: What Is the Difference?

A predetermination is a voluntary request asking a dental plan to estimate what it would pay for a planned treatment before the work begins. A pre-authorization, by contrast, is approval a plan requires before certain services are covered at all. Offices often use the words interchangeably, but the ADA treats them as distinct, and mixing them up leads to the wrong expectations for both the office and the patient.

People searching for “predetermination insurance” usually want to know whether they need one, how long it takes and whether it guarantees payment. This guide covers what a dental predetermination is, how it differs from a dental pre-authorization, when Medicaid programs require prior authorization, how to submit each one and how to use the answer in a patient estimate.

What is a predetermination in dental insurance?

The ADA describes a predetermination as a voluntary service, common with dental PPO and indemnity plans, that shows what the plan would cover and pay for proposed treatment. Carriers use different names for it. Northeast Delta Dental, for example, calls it a pre-treatment estimate and notes it is also called a predetermination.

The response usually lists each proposed procedure with the allowed amount, the plan’s payment, the patient’s estimated share and any procedure the plan would downgrade, limit or deny. The estimate depends on the patient still being eligible and having benefits left when the work is done.

How is a dental pre-authorization different?

A pre-authorization is a gate rather than an estimate. The ADA notes that dental HMO plans often require pre-authorization before a patient is referred to a specialist, so the plan can review the proposed treatment and authorize payment. Medicaid dental programs also commonly require prior authorization for specific services. Skip it, and the claim may be denied even if the treatment was appropriate.

Is a predetermination a guarantee of payment?

No, and neither is a pre-authorization. The ADA is direct on this point: benefits depend on the coverage in effect on the date of service, not the date the request was sent. A predetermined case can still be denied if the patient loses coverage, uses up the annual maximum on other claims, or moves into a new benefit year with different terms. The ADA suggests submitting predeterminations for complex, costly treatment as close to the service date as practical and telling patients clearly that the response is not a guarantee.

When do Medicaid dental programs require prior authorization?

Medicaid dental benefits are set by each state. Federal rules require dental coverage for children under the EPSDT benefit, while adult dental benefits are left to each state. Prior authorization rules vary just as much, so the state’s provider billing guide or the managed care plan’s provider manual is the only reliable source.

Washington’s Apple Health program is one published example. Its dental billing guide lists services that need prior authorization, including many removable prosthodontic procedures, certain restorative services and some treatment performed in a hospital or surgery center. The guide says prior authorization must be obtained before the service, that approval indicates only that the service is clinically necessary, that it does not guarantee payment and that it is valid only if the patient is eligible on the date of service. Other states have their own lists and forms. Our article on Medicaid and Medicare dental billing covers how those programs differ from commercial plans.

How do you submit a predetermination or pre-authorization?

1. Use the ADA claim form or the electronic equivalent. In the header, mark the request for predetermination or preauthorization box, and leave dates of service blank, since the work has not been done. The ADA’s completion instructions describe this.
2. List each planned procedure with the CDT code, tooth number, surfaces and your full fee.
3. Attach the supporting records: recent radiographs, periodontal charting, photos and a narrative where needed. Medicaid programs often require their own form as well.
4. Record the reference number the carrier returns. When you file the claim after treatment, enter the predetermination or preauthorization number in item 2 of the ADA claim form.
5. Track the response. Set a follow-up date in your software and call or check the portal if nothing arrives.

Our Insurance Verification & Eligibility team confirms whether a plan requires authorization for planned treatment and tracks predeterminations through to a response.

How long does a dental predetermination take?

Turnaround depends on the carrier, how complete the submission is and whether a dental consultant has to review it. Electronic submissions with all attachments generally move faster than paper. Missing radiographs or a vague narrative are the most common reasons a request is returned or delayed. Avoid scheduling treatment on the assumption of a fixed turnaround; schedule once the response arrives or once the patient agrees to proceed without it.

Also watch expiration. Some approvals are valid only for a set period. Washington’s guide, for example, says its prior authorizations are valid for 6 to 12 months as stated in the approval letter. If treatment slips past that date or into a new benefit year, submit again.

What do common predetermination responses mean?

The response is only useful if the team reads it line by line. The results you will see most often:

• Approved as submitted. The plan expects to pay its normal percentage of its allowed amount, subject to eligibility and remaining benefits on the date of service.
• Alternate benefit. The plan will pay as if a less costly procedure were done, such as a different restoration material. The patient pays the difference.
• Limited by frequency or replacement rules. A prior service on the same tooth falls inside the plan’s window, so the plan will pay nothing or will pay only after a later date.
• Not a covered benefit. The plan excludes the service, for example under an implant exclusion or a missing tooth clause.
• Additional information requested. The reviewer needs radiographs, charting or a narrative. Send it promptly, because the request is on hold until you do.

Record the outcome for each line in the patient’s treatment plan so the person presenting the case can explain it.

How do you turn the response into a patient estimate?

Use the carrier’s response as the starting point, then check it against what has changed since. Confirm current eligibility, remaining annual maximum, deductible status and any frequency limits that other recent claims may have used. Show any downgrade or alternate benefit as a separate line so the patient sees why the plan pays less than expected.

Our dental patient estimate calculator walks through coinsurance, deductibles and maximums for each procedure, and the dental annual maximum calculator shows how a large case may need to be split across benefit years. Give the patient the estimate in writing, with a clear note that the plan decides final payment when the claim is processed.

When is a predetermination worth sending?

• Large restorative, prosthetic or implant cases.
• Cases where a missing tooth clause, downgrade or frequency limit may apply.
• Periodontal surgery and other treatment carriers often review closely.
• Patients who will not proceed without knowing their cost.

For routine fillings and preventive care, a good benefits verification is usually enough.

If predeterminations and authorizations are slowing down your case acceptance, book a free consultation and we will review how your office handles them today.