Predeterminations overview

What is a predetermination?

A predetermination is a type of insurance claim that you use to confirm that a procedure is covered by a patient's insurance carrier and how much of the cost they expect to cover.

Predeterminations are not a guarantee of payment and may only be valid for a defined time period.

Some carriers may only reimburse certain treatments if a predetermination is submitted before treatment.

What procedures require a predetermination?

The rules for what treatments require predeterminations are configured in Practice > Insurance > Policies and Payers at the insurance policy level.

Predeterminations can be required for all treatment in a certain category or as exceptions for specific codes. To learn more, see Manage insurance payers and policies.

How do I know if a procedure requires a predetermination?

Procedures that require predeterminations display a note in the  or  requirements popover in Treatment Planning and the General Procedure List.

Selecting the predetermination note displays the current status of the predetermination and insurance policy details.

If the predetermination is missing can I proceed with treatment?

If a procedure requires a predetermination and it is hasn't been received and processed, the system displays a warning if a clinician tries to move the procedure to In Progress or Completed.

If the clinician intends on proceeding with treatment, they must acknowledge that a predetermination is being excluded for each of the patient's policies that require it.

Orthodontic treatment plans also display warnings if the associated orthodontic treatment code requires predetermination.

Prior Authorizations & Medicaid

For practices in the United States, you can also use the predetermination workflow to create prior authorizations for medicaid policies.

The forms used for these are configured at the insurance policy level.